Admission Date: [**2118-6-2**] Discharge Date: [**2118-6-14**]Date of Birth: Sex: FService: MICU and then to [**Doctor Last Name **] MedicineHISTORY OF PRESENT ILLNESS: This is an 81-year-old femalewith a history of
emphysema
DISEASE
(not on home O2) who presentswith three days of
shortness of breath
DISEASE
thought by her primarycare doctor to be a
COPD
DISEASE
flare. Two days prior to admissionshe was started on a prednisone taper and one day prior toadmission she required oxygen at home in order to maintainoxygen saturation greater than 90%. She has also been onlevofloxacin and nebulizers and was not getting better andpresented to the [**Hospital1 18**] Emergency Room.In the [**Hospital3 **] Emergency Room her oxygen saturation was100% on CPAP. She was not able to be weaned off of thisdespite nebulizer treatment and Solu-Medrol 125 mg IV x2.Review of systems is negative for the following: Fevers
chills nausea vomiting
DISEASE
night
sweats
DISEASE
change in weight
gastrointestinal complaints neurologic changes rashes
DISEASE
palpitations orthopnea
DISEASE
. Is positive for the following:Chest pressure occasionally with
shortness of breath
DISEASE
withexertion some
shortness of breath
DISEASE
that is positionallyrelated but is improved with nebulizer treatment.PAST MEDICAL HISTORY:1.
COPD
DISEASE
. Last pulmonary function tests in [**2117-11-3**]demonstrated a FVC of 52% of predicted a FEV1 of 54% ofpredicted a MMF of 23% of predicted and a FEV1:FVC ratio of67% of predicted that does not improve with bronchodilatortreatment. The FVC however does significantly improve withbronchodilator treatment consistent with her known reversibleair flow obstruction in addition to an underlying restrictiveventilatory defect. The patient has never been on homeoxygen prior to this recent episode. She has never been onsteroid taper or been intubated in the past.2. Lacunar
CVA
DISEASE
. MRI of the head in [**2114-11-4**]demonstrates Admission Date: [**2125-2-9**] Discharge Date: [**2125-2-16**]Service: MEDICINE
Allergies
DISEASE
:Zocor / LescolAttending:[**Doctor Last Name 1857**]Chief Complaint:
Chest pain
DISEASE
Major Surgical or Invasive Procedure:Central venous line insertion (right internal jugular vein)History of Present Illness:Mr. [**Known lastname 1858**] is an 84 yo man with moderate
aortic stenosis
DISEASE
(outsidehospital echo in [**2124**] with [**Location (un) 109**] 1 cm2 gradient 28 mmHg moderate
mitral regurgitation
DISEASE
mild
aortic insufficiency
DISEASE
) chronic left
ventricular systolic heart failure
DISEASE
with EF 25-30%
hypertension
DISEASE
hyperlipidemia diabetes mellitus CAD
DISEASE
s/p CABG in [**2099**] withSVG-LAD-Diagonal SVG-OM and SVG-RPDA-RPL with a re-do CABG in[**9-/2117**] with LIMA-LAD SVG-OM SVG-diagonal and SVG-RCA. He alsohas severe
peripheral arterial disease
DISEASE
s/p peripheral bypasssurgery. He presented to [**Hospital 1474**] Hospital ER this morning with
shortness of breath and chest pain
DISEASE
and was found to be in
heart
failure
DISEASE
.He states he was in his usual state of health until 10:30 lastevening when he woke up feeling coldAdmission Date: [**2119-5-12**] Discharge Date: [**2119-5-18**]Date of Birth: [**2079-3-9**] Sex: MService: SURGERY
Allergies
DISEASE
:Percocet / LisinoprilAttending:[**First Name3 (LF) 301**]Chief Complaint:substernal
chest pain
DISEASE
Major Surgical or Invasive Procedure:1. Closure of perforated
ulcer
DISEASE
.2. Partial gastrectomy.3. Cholecystectomy.4. Omental patch of
ulcer
DISEASE
.History of Present Illness:40 M who is 2 years s/p laparoscopic RNY gastric bypasspresents to ED after transfer from [**Hospital6 302**] with a CTscan showing pneumoperitoneum. Mr. [**Known lastname 303**] reports sudden onsetof substernal
chest pain
DISEASE
at 5 am.
Pain
DISEASE
was severe and his firstthought was that he was having an MI.
Pain
DISEASE
unrelieved withattempt at bowel movement. He denies
fevers chills nausea
DISEASE
vomiting
DISEASE
or any other symptoms. No radiation of the
pain
DISEASE
.Cardiac work-up at OSH was negative however abdominal CT showedpneumoperitoneum.
Pain
DISEASE
was relieved with dilaudid 4 hrs ago. Hecurrently denies
abdominal pain
DISEASE
and feels much better.Past Medical History:
HTN
DISEASE
hypothyroidism
DISEASE
back pain
DISEASE
w/sciaticaplantar
fasciitis
DISEASE
Social History:He denied tobacco or recreational drug usagehas alcoholic beverages on rare occasions drinks iced coffeeanddiet soda several times per week. He is employed as alaboratorytechnologist in the chemistry lab at [**Hospital1 18**]. He is marriedlivingwith his wife age 38 and they have one son age 6 months.Family History:His family history is notedfor father living age 75 with
thyroid diseaseAdmission
DISEASE
Date: [**2160-8-4**] Discharge Date: [**2160-8-12**]Date of Birth: [**2099-6-29**] Sex: MService: MEDICINE
Allergies
DISEASE
:MorphineAttending:[**First Name3 (LF) 3853**]Chief Complaint:Admission Date: [**2109-3-14**] Discharge Date: [**2109-4-3**]Service: [**Hospital1 139**]CHIEF COMPLAINT: Fevers.HISTORY OF PRESENT ILLNESS: The patient is an 84-year-oldfemale with a past medical history significant for
Parkinson
disease
DISEASE
with associated [**Last Name (un) 309**] body
dementia
DISEASE
and a long historyof
tobacco abuse
DISEASE
who was noted with
fevers
DISEASE
.The patient was in her usual state of health until two weeksprior to admission when she developed
rhinorrhea
DISEASE
. Thepatient and her daughter deny any other symptoms at thattime.However on the evening of [**2109-3-12**] the patientreports that she developed
pain
DISEASE
in the right side of herneck. The following day she had a temperature to 101 withcontinued
intermittent right-sided neck pain
DISEASE
. She was again
febrile
DISEASE
on the morning of admission and called her primarycare physician for his advise. He suggested that she reportto the Emergency Department for further evaluation.In the Emergency Department the patient's vital signsrevealed a temperature of 100 degrees Fahrenheit her heartrate was 75 her blood pressure was 93/46 her respiratoryrate was 18 and her oxygen saturation was 96% on room air.A chest x-ray in the Emergency Department showed consistent
cardiomegaly
DISEASE
. An
opacity
DISEASE
in the right lower lobe withprobable right
pleural effusion
DISEASE
was identified. There was no
pneumothorax
DISEASE
. The patient was started on levofloxacin for apresumed
community-acquired pneumonia
DISEASE
. Blood cultures wereobtained.REVIEW OF SYSTEMS: On review of systems the patient reportsthat she has Admission Date: [**2157-4-9**] Discharge Date: [**2157-4-18**]Date of Birth: [**2106-1-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 30**]Chief Complaint:
vomiting
DISEASE
blood clotsMajor Surgical or Invasive Procedure:noneHistory of Present Illness:50 yo M with h/o EtOH abuse and
HTN
DISEASE
who presents with
emesis
DISEASE
with blood clots. Pt states he was
vomiting
DISEASE
for 24 hours beforecoming to the ED. States he last consumed EtOH 2 days PTA andthat he drank about a fifth of wine x 2. States he was sleepingat the [**Hospital3 328**] and vomited again with red clots. Denies CPSOB
palpitations
DISEASE
F/C
nausea
DISEASE
BRBPR. No black stools
constipation
DISEASE
or
diarrhea
DISEASE
. No
dysuria
DISEASE
.Past Medical History:EtOH abuse
HTN
DISEASE
Admission Date: [**2157-5-11**] Discharge Date: [**2157-5-14**]Date of Birth: [**2106-1-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 330**]Chief Complaint:etoh withdrawal
seizure
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:50 y/o male w/ h/o EtOH abuse
UGI bleed
DISEASE
htn
pancreatitis
DISEASE
EtOH withdrawal sz presenting w/ EtOH intox and c/o abd
pain
DISEASE
b/land nonspecific
pain
DISEASE
Admission Date: [**2157-5-31**] Discharge Date: [**2157-6-1**]Date of Birth: [**2106-1-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 338**]Chief Complaint:
tremors nausea vomiting
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:50 y/o M w/ h/o ETOH abuse who p/w
tremors tachycardia
DISEASE
nausea vomiting
DISEASE
x 2 days. These symptoms started after hestopped drinking ETOH 2 days prior to admission. He notes thathe threw up multiple times including a small amount of brightred
hematemesis
DISEASE
. He reports associated
abdominal pain
DISEASE
andtremulousness. Admission Date: [**2128-5-5**] Discharge Date: [**2128-5-7**]Date of Birth: [**2067-10-12**] Sex: MService:HISTORY OF PRESENT ILLNESS: The patient is a 60 year oldright handed man with a history of long-standing
seizure
DISEASE
disorder
DISEASE
and a
right frontal anaplastic ganglioglioma
DISEASE
with
oligodendroglioma
DISEASE
differentiation. He is status postresection in [**2124-5-10**] and involved field cranialirradiation. He had progressively deteriorated withinability to walk being the most troublesome. He is nolonger able to get his left leg to move when standing and hefeels the left arm is also weaker and his speech is muchworse. His verbal responses are much slower and he hassignificant word finding difficulty. The
pain
DISEASE
in the leftleg at times is intense and the Morphine has helped withthis.PHYSICAL EXAMINATION: On physical examination his bloodpressure was 118/70 pulse 60 respiratory rate 18. Thehead eyes ears nose and throat is within normal limits.The lungs are clear. The heart has regular rate and rhythm.The abdomen is obese nontender. The extremities are without
edema
DISEASE
. Neurologically his speech is slower with wordfinding difficulty and long pauses. His pupils are 4.0millimeters and equally reactive to light. His visual fieldsand
extraocular movements
DISEASE
are full. Hearing is decreased inthe left ear. He has slight
left facial droop
DISEASE
. The tongueis midline. Palate rises symmetrically. There is a left armdrift. Shoulder shrug is decreased on the left. The leftarm is 4Admission Date: [**2128-5-5**] Discharge Date: [**2128-5-7**]Date of Birth: [**2067-10-12**] Sex: MService:HISTORY OF PRESENT ILLNESS: The patient is a 60 year oldright handed man with a history of long-standing
seizure
DISEASE
disorder
DISEASE
and a
right frontal anaplastic ganglioglioma
DISEASE
with
oligodendroglioma
DISEASE
differentiation. He is status postresection in [**2124-5-10**] and involved field cranialirradiation. He had progressively deteriorated withinability to walk being the most troublesome. He is nolonger able to get his left leg to move when standing and hefeels the left arm is also weaker and his speech is muchworse. His verbal responses are much slower and he hassignificant word finding difficulty. The
pain
DISEASE
in the leftleg at times is intense and the Morphine has helped withthis.PHYSICAL EXAMINATION: On physical examination his bloodpressure was 118/70 pulse 60 respiratory rate 18. Thehead eyes ears nose and throat is within normal limits.The lungs are clear. The heart has regular rate and rhythm.The abdomen is obese nontender. The extremities are without
edema
DISEASE
. Neurologically his speech is slower with wordfinding difficulty and long pauses. His pupils are 4.0millimeters and equally reactive to light. His visual fieldsand
extraocular movements
DISEASE
are full. Hearing is decreased inthe left ear. He has slight
left facial droop
DISEASE
. The tongueis midline. Palate rises symmetrically. There is a left armdrift. Shoulder shrug is decreased on the left. The leftarm is 4Admission Date: [**2128-5-12**] Discharge Date: [**2128-5-18**]Date of Birth: [**2067-10-12**] Sex: MService: #58HISTORY OF PRESENT ILLNESS: The patient is a 60 year-oldgentleman with a past medical history of a right frontalantiplastic
oligodendroglioma
DISEASE
status post resection in [**5-/2124**]and 3/[**2128**]. He was just recently discharged from [**Hospital1 346**] after the most recent resection ofthis
tumor
DISEASE
and was sent to [**Hospital **] Rehab where he developeda
headache
DISEASE
. A CT scan showed postop changes withoutexcessive
edema
DISEASE
or midline shift and the patient was sentback to [**Hospital **] Rehab. Upon return he was noted to havedeveloped a
fever
DISEASE
to 103 axillary and the patient was notedto be more lethargic with mental status changes so he wassent back to the Emergency Room for reevaluation.PAST MEDICAL HISTORY: As above.ALLERGIES: Percocet. The patient now reports a history ofitching red
rash
DISEASE
from Percocet.PHYSICAL EXAMINATION: Vital signs temperature 103.4rectally. Blood pressure 170/86. Heart rate 84. Respiratoryrate 20. Sat 97% on 2 liters. HEENT the patient is statuspost a right frontal craniotomy with moderate amount of
subgaleal
DISEASE
fluid collection which remains ballotable. Pupilsare equal round and reactive to light. He is sleepy butarousable. He has short verbal communication and shortverbal responses to questions but no spontaneous speech.His neck is mildly stiff with some
nuchal rigidity
DISEASE
. Thechest has basilar crackles. Heart regular rate and rhythm.Abdomen soft nontender nondistended. Positive bowelsounds. Extremities no
clubbing cyanosis
DISEASE
or
edema
DISEASE
.Neurological examination limited due to
lethargy
DISEASE
. The patientis arousable. He follows some commands inconsistently. Hemoves all extremities but is noncompliant with strengthexamination. Subgaleal fluid collection was tapped and sentfor culture. The patient also had an LP. Cerebral spinalfluid was minimally cloudy and sent for cell count gramstain and culture and sensitivity which grew out rare growthstaph coag negative. The patient has been treated withintravenous antibiotics Vancomycin Ceftazidime 2 gramsintravenous q 8 hours times four weeks.LABORATORIES ON ADMISSION: White blood cell count was 27.7hematocrit 42.3 platelets 359 sodium 134 K 4.1 chloride95 CO2 27 BUN 23 creatinine .9 glucose 99. His Depakotelevel was 48 on admission. His urine was negative.HOSPITAL COURSE: He was admitted for close observation tothe Surgical Intensive Care Unit. He was seen by the
Infections Disease
DISEASE
Service who recommended continuing theVancomycin and Ceftazidime and discontinuing Ceftriaxone forantibiotic coverage. He was transferred to the floor onhospital day number two. He was seen by physical therapy andoccupational therapy and found to require rehab prior todischarge to home. He had PICC line placed for long termantibiotics. His vital signs remained stable and he has beenafebrile throughout his hospital stay. His mental status heis awake alert and oriented times three moving allextremities strongly with good strength throughout. He hasbeen out of bed ambulating with physical therapy but stillrequires some rehab before discharged to home. His PICC lineis in place and he will continue on Vancomycin Ceftazidimefor four weeks time and follow up with
Infectious Disease
DISEASE
Service and Dr. [**First Name (STitle) **] in three to four weeks time.MEDICATIONS ON DISCHARGE: Lamictal 150 mg po q day Celexa20 mg po q day at h.s. Zantac 150 mg po b.i.d. Decadron 2mg po q 12 hours MS Contin 15 mg po b.i.d. Vancomycin 1gram intravenous q 12 hours Ceftazidime 2 grams intravenousq 8 hours Tylenol 650 po q 4 hours prn.CONDITION ON DISCHARGE: Stable at the time of discharge. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**] M.D. [**MD Number(1) 343**]Dictated By:[**Last Name (NamePattern1) 344**]MEDQUIST36D: [**2128-5-18**] 10:57T: [**2128-5-18**] 11:16JOB#: [**Job Number 347**]Admission Date: [**2196-10-14**] Discharge Date: [**2196-10-18**]Service: MEDICINE
Allergies
DISEASE
:HydrochlorothiazideAttending:[**First Name3 (LF) 348**]Chief Complaint:DizzynessMajor Surgical or Invasive Procedure:Hypertonic saline infusionHistory of Present Illness:Mr. [**Known lastname 349**] is an 89 year old man who presented with severalmonths of
dizziness thirst
DISEASE
and increased
urination
DISEASE
. He wasconfused and found to be
hyponatremic
DISEASE
head CT negative CXRclear UA negative. The patient is unable to recount a historydue to word finding difficulties. He is however alert andoriented times three. When asked if there was someone to call toget more information about him he responded that his sisterwould be unable to help and he has no children as he was nevermarried..ED course: Vitals: T 98 80 134/90 12 100% on
RA
DISEASE
. He receivedIVF 60 mEq of KCL and was free water restricted. 1L normalsaline over 3 hours..On the floor the patient is confused but easily redirectable.He is aware he is in the hospital and has no current complaints.Past Medical History:-HTN-Hypercholesterolemia-Unknown facial nerve condition - Admission Date: [**2126-7-29**] Discharge Date: [**2126-8-20**]Date of Birth: [**2048-6-6**] Sex: FService: TRAHISTORY OF PRESENT ILLNESS: Seventy-eight-year-old femaleinvolved in a motor vehicle accident. She was an unrestraineddriver with no
loss of consciousness
DISEASE
but was hit by a dumptruck with significant intrusion into the car. She has
complaint
DISEASE
of
chest pain
DISEASE
and systolic blood pressure of 88 andheart rate of 100 in the field.PAST MEDICAL HISTORY: Amyloidosis depression kidneystones.PAST SURGICAL HISTORY: Breast implants 30 years ago tuballigation left hip replacement question of
kidney stone
DISEASE
surgery.ALLERGIES: No known
drug allergies
DISEASE
.MEDICATIONS: Prozac.SOCIAL HISTORY: Two cigarettes per day 1-2 drinks per day.PHYSICAL EXAMINATION: Temperature was 99.4 heart rate 92blood pressure 115/40 respiratory rate 20 and 94% on facemask. She has a
GCS
DISEASE
of 15. Pupils were equal and reactive.Trachea was midline. Heart was regular rate and rhythm.Abdomen was soft nontender nondistended. There was gross
hematuria
DISEASE
visible. The pelvis was stable but slightlytender. Rectal was guaiac negative. Back had some abrasionsbut no step-offs. There were some abrasions of theextremities but no gross deformity.LABS: White blood cell count is 12.6 hematocrit 24.9platelets 241. Chem-7 with a sodium of 142 potassium 4.0chloride 110 bicarbonate 19 BUN 39 creatinine 1.3 glucose114. Amylase is 133. Toxicology screen was negative.Head CT was negative.C. spine CT shows C2
fracture
DISEASE
through the transverse foramenbilaterally.Chest CT showed bilateral small
pneumothoraces
DISEASE
with bilateralrib
fractures
DISEASE
bilateral
pulmonary contusions
DISEASE
.Abdomen and pelvis CT showed a
splenic laceration
DISEASE
with nofree fluid blood in the left renal pelvis with blood in theureter. There is a small
liver laceration
DISEASE
and a sacral
fracture
DISEASE
as well as left iliac [**Doctor First Name 362**] small
fracture
DISEASE
.HOSPITAL COURSE: Patient was admitted to the
trauma
DISEASE
intensive care unit for close observation. Patient was seenby the [**Doctor First Name **] service and was recommended to have anephrostomy tube placed which was done. There was difficultywith the initial nephrostomy tube and interventionalradiology inserted the nephrostomy tube.Patient was seen by the thoracic surgery service for thebilateral
pneumothoraces
DISEASE
. Chest tubes were attempted butunable to be passed due to scarring and the lungs cleared.Patient was seen by the orthopedic spine service as well. Itwas determined that the C2
fracture
DISEASE
would require a hardcollar for at least 8-12 weeks.Patient was in the
trauma
DISEASE
intensive care unit withhematocrits being followed serially. On the evening of[**8-2**] patient's serial hematocrits were significantlyaltered. Patient dropped her blood pressure becamehemodynamically stable and the hematocrit was in the midteen's. It was decided at this time patient will be broughtto the emergency room emergently to have an open splenectomy.Postoperatively the patient was again brought to the
trauma
DISEASE
intensive care unit. We gradually weaned the patient from theventilator over the course of the next 15-20 days. Patienthad some sputum samples which revealed some gram-negativerods for which she was started on levofloxacin. A 14-daycourse of that was to be initiated. Patient was started onnutrition with ProMod with fiber by Dobbhoff feeding tube. Apercutaneous tracheostomy was performed on [**8-9**]successfully.On the last few days in the intensive care unit patient wasable to wean to a tracheostomy collar. This was toleratedwell. Speech and swallow was done the day of discharge whicha Passy-Muir valve was not tolerated for extended periods oftime. However it was felt in due time patient would be ableto swallow on her own in a relatively short period of time.CONDITION ON DISCHARGE: Stable.DISCHARGE STATUS: Extended care facility.DISCHARGE DIAGNOSIS: Status post splenectomy.DISCHARGE MEDICATIONS: Listed on but they consistent ofacetaminophen 325 mg p.o. q.4-6h. p.r.n. fluoxetine 20 mgdaily insulin sliding scale albuterol nebulizer 1-2 puffsq.6h. p.r.n. Artificial Tears 1-2 drops both eyes p.r.n.Artificial Tears ointment 1 both eyes p.r.n. aspirin 325daily Dulcolax 10 mg p.r./p.o. p.r.n. daily Diazepam 5 mgp.o. q.12h. p.r.n. Colace 100 mg p.o. b.i.d. Lovenox 40 mgsubcutaneously daily Prevacid 30 mg p.o. daily levofloxacin500 mg p.o.
q.24h
DISEASE
. for 3 more days Lopressor 25 mg p.o.daily and oxycodone liquid 5-10 mg p.o. q.4h. p.r.n.
pain
DISEASE
.FOLLOW UP: Patient will follow up with Dr. [**Last Name (STitle) 363**] fromorthopedic Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 364**] [**Name5 (PTitle) **] service Dr. [**Last Name (STitle) 365**]in approximately 2 weeks and the
trauma
DISEASE
clinic inapproximately 2 weeks. [**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**] [**MD Number(1) 367**]Dictated By:[**Name8 (MD) 368**]MEDQUIST36D: [**2126-8-20**] 11:13:44T: [**2126-8-20**] 11:48:24Job#: [**Job Number 369**]cc:[**Hospital1 370**]Admission Date: [**2192-4-19**] Discharge Date: [**2192-5-23**]Service: MEDICINE
Allergies
DISEASE
:LisinoprilAttending:[**First Name3 (LF) 1865**]Chief Complaint:
Diarrhea
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Mrs. [**Known lastname **] is an 84 yo f h/o CRI
HTN
DISEASE
GERD colon caneprhotic syndrome dc'd [**3-31**] after low anterior resection ofcolon. Now p/w 1wk h/o
diarrhea
DISEASE
worsened one day prior toadmission found to have wbcc 30 in ED admitted [**4-19**] andstarted on both p.o. vanco and IV flagyl. Began to have brbpr on[**4-25**] on [**4-30**] had flex sigmoidoscopy showing
pseudomembranes
DISEASE
withrecurrent c.diff vs. bowel ischemia as etiology. Then developedsome sob/fluid
overload
DISEASE
and was started on lasix and neseritidegtt's. Had had some intermittent afib which was thought to becontributing to presumed
diastolic dysfunction
DISEASE
. Tx to CCU[**2192-5-12**] for worsening
tachypnea
DISEASE
and
oliguria
DISEASE
on nesiritide andlasix gtt. Was cardioverted chemically with good result. Alsodeveloped acute on
chronic renal failure
DISEASE
for which nephrologyhas been following zenith of 6.0 now back at baselinecreatinine of 2.0's.Past Medical History:Recent admission to [**Hospital1 18**] from [**2192-2-17**] to [**2192-2-29**] for treatmentof likely
viral gastroenteritis
DISEASE
PNA
transaminitis
DISEASE
dischargedto [**Hospital **] Rehab in [**Hospital1 8**]- RAS: MRI ([**2185**])
atrophic R kidney mod stenosis of R renal
artery L renal artery
DISEASE
normal- CRI/nephrotic range
proteinuria
DISEASE
: [**2191**] baseline Cr 2.5Admission Date: [**2126-8-23**] Discharge Date: [**2126-9-19**]Date of Birth: [**2048-6-6**] Sex: FService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 371**]Chief Complaint:HISTORY OF PRESENT ILLNESS: Seventy-eight-year-old femaleinvolved in a motor vehicle accident. She was an unrestraineddriver with no
loss of consciousness
DISEASE
but was hit by a dumptruck with significant intrusion into the car. She has
complaint
DISEASE
of
chest pain
DISEASE
and systolic blood pressure of 88 andheart rate of 100 in the field.78F re-admit (s/p MVC with c spine fx/pulm contusions/rib fx s/ptrach/spenic lac s/p splenectomy/pelvic fx) - from rehab
septic
DISEASE
picture likely aspiration
pneumonia
DISEASE
secondary to dobhoff beingplaced into lung.Major Surgical or Invasive Procedure:placement of G tubeHistory of Present Illness:HISTORY OF PRESENT ILLNESS:78F re-admit (s/p MVC with c spinefx/pulm contusions/rib fx s/p trach/spenic lac s/psplenectomy/pelvic fx) - from rehab
septic
DISEASE
picture likelyaspiration
pneumonia
DISEASE
secondary to dobhoff being placed intolung. Seventy-eight-year-old femaleinvolved in a motor vehicle accident. She was an unrestraineddriver with no
loss of consciousness
DISEASE
but was hit by a dumptruck with significant intrusion into the car. She has
complaint
DISEASE
of
chest pain
DISEASE
and systolic blood pressure of 88 andheart rate of 100 in the field.admitted to [**Hospital1 18**] on [**7-29**] with C2
fracture
DISEASE
bilateral pleural
hematomas
DISEASE
L
breast implant rupture
DISEASE
rib
fractures
DISEASE
spleniclaceration s/p splenectomy and s/p nephrostomy tube placementwho returned to [**Hospital1 18**] from rehab on [**8-23**] with
hypoxia
DISEASE
and
respiratory distress
DISEASE
.Past Medical History:PMH:
Amyloidosis depression kidney stones
DISEASE
hx of tubal ligation Lhip replacementSocial History:SH: 2 cigs per day 1-2 drinks per dayFamily History:
FH
DISEASE
: daughter [**Name (NI) 372**] is currently undergoing temporaryguardianshipPhysical Exam:Tc afebrile HR 96 BP 161/67 RR 34 99% on PS[**7-5**] 40% FI02Gen: lying in bed eyes open minimal mvmt.HEENT: trach in place copious sputum out of trach openingcoughingmmm OP benignNeck: in C collarCV: RRR difficult to auscultate given breath soundsResp: coarse upper airway sounds bilaterallyAbd: multiple dressings covering postop incisions ileostomy bagc/d/iExt: warm well perfusedSkin: ecchymoses on legs and arms.MS: Awake opens eyes to voice but not command and looks torightat calling of name not consistently to left. Wiggles toes tocommands will not squeeze hands to command will not lift armsto command.CN: PERRLA blinks to threat bilaterally. Full eye movementshorizontally but seems to have R gaze preference. No evidence of
nystagmus
DISEASE
no
ptosis
DISEASE
. Grimaces to stim on both sides of face.Corneal reflex present. Face symmetric but difficult to assesswtih collar. Hears voice. No speech. Admission Date: [**2137-3-7**] Discharge Date: [**2137-3-16**]Date of Birth: [**2060-10-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:LisinoprilAttending:[**First Name3 (LF) 348**]Chief Complaint:
Acute renal failure
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness: 76 yo male w/PMHx sx for
chronic kidney disease cirrhosis
DISEASE
[**1-31**]
NASH
DISEASE
vs. PSC with resultant
ascites
DISEASE
and Grade II esophagealvarices
DM2
DISEASE
PSC and CAD who presents with acute worsening ofcreatinine. Patient has
chronic kidney disease
DISEASE
with baselinecreatinine of 1.8 now elevated to 4.8 with potassium 5.8. His
CKD
DISEASE
is thought [**1-31**]
HTN
DISEASE
and
DM2
DISEASE
. He recently received therapeuticparacentesis with removal of 3.5L of fluid negative for SBP. Hestates that he has noticed increasing
abdominal distension
DISEASE
and
fatigue
DISEASE
over the past several weeks. He has not noticedincreased
pruritus confusion
DISEASE
delta MS..He has taken recent antibiotics and states that his po intakehas been poor due to lack of appetite. He says that his urineoutput has been about the same as prior. Denies use of NSAIDS athome. He has not been able to walk long distances because of hisLE
swelling
DISEASE
.
Denies CP/SOB/DOE/F/C/N/V/BRBPR/melena
DISEASE
.Past Medical History:1) Right Popliteal
DVT
DISEASE
. (s/p IVC filter)2) DM type 2Admission Date: [**2167-10-20**] Discharge Date: [**2167-10-27**]Date of Birth: [**2098-7-31**] Sex: FService: MEDICINE
Allergies
DISEASE
:Macrodantin / Sulfonamides / Compazine / Atorvastatin /Lovastatin / MetoprololAttending:[**First Name3 (LF) 398**]Chief Complaint:Transfer for
respiratory failure
DISEASE
Major Surgical or Invasive Procedure:PA catheter placementHistory of Present Illness:Ms. [**Name14 (STitle) 399**] is a 69 year-old female with a history of
diabetes coronary artery disease COPD
DISEASE
who presents on transferfor
respiratory distress
DISEASE
..Per review of OSH records: Patient presented to OSH withcomplaints of [**2-7**] days of
cough
DISEASE
and
dyspnea
DISEASE
. On the day priorto transfer she ws out in public and experienced a sudden onsetof worsened
dyspnea
DISEASE
. She asked bystanders to call EMS and bythe time they arrived she was found unresponsiveAdmission Date: [**2143-4-1**] Discharge Date: [**2143-4-5**]Date of Birth: [**2095-2-27**] Sex: FService: Cardiothoracic SurgeryCHIEF COMPLAINT/REASON FOR ADMISSION: Ms. [**Known firstname **] [**Known lastname 403**] isa postoperative admission who was admitted directly to theoperating room for mitral valve repair versus replacement.She was seen in preadmission testing prior to surgery. Atthat time her chief
complaint
DISEASE
was occasional
dyspnea
DISEASE
onexertion.HISTORY OF PRESENT ILLNESS: This is a 47-year-old woman withknown
mitral regurgitation
DISEASE
followed by electrocardiogram.Cardiac catheterization done showed 3 to 4Admission Date: [**2174-6-19**] Discharge Date: [**2174-7-4**]Date of Birth: [**2093-11-17**] Sex: FService: MEDICINE
Allergies
DISEASE
:AtorvastatinAttending:[**First Name3 (LF) 425**]Chief Complaint:
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:Intubation and mechanical ventilationTransesophageal echocardiogramEsophagogastroduodenoscopyHistory of Present Illness:Ms. [**Known lastname 426**] is an 80yo woman with h/o CAD s/p recent PCI severeAS s/p valvuloplasty [**4-/2174**] and recently treated for possible
pneumonia
DISEASE
with ceftazidime [**Date range (1) 427**] admitted with
shortness of
breath
DISEASE
and
hypotension
DISEASE
.Ms. [**Known lastname 428**] husband reports that he has observed her breathingvery fast around 3 or 4 in the morning for the last couple ofnights. On the day of admissin she woke up short of breath andbreathing quickly. He used a stethoscope (which he has to helpwith home maintenance) and heard a hissing/wheezing on her rightchest which prompted him to call 911. She continued breathingfast until she was intubated in the ED with her consent. Henotes that she has had a minimally productive
cough
DISEASE
since herlast admission though she has not had
fevers
DISEASE
or
chills
DISEASE
. Shehad
diarrhea
DISEASE
for about a day recently but this has resolved.Her nephrologist contact[**Name (NI) **] her on [**6-16**] and advised her todecrease her lasix from 160mg daily to 80mg because of herrising creatinine. Despite this change her daily weight hasremained stable at 119-120 pounds. She has been compliant with1L fluid restriction.In the ED her initial VS were: 99.8 115 122/75 30s 82%NRB. She was noted to have crackles on her pulmonary exam. Shewas given rocuronium etomidate and versed and intubatedurgently. Shortly after propofol gtt was started she droppedher pressures into the into the 70s (per reportAdmission Date: [**2174-7-17**] Discharge Date: [**2174-7-20**]Date of Birth: [**2093-11-17**] Sex: FService: MEDICINE
Allergies
DISEASE
:AtorvastatinAttending:[**First Name3 (LF) 443**]Chief Complaint:
Shortness of breath
DISEASE
Major Surgical or Invasive Procedure:Transfused 2 units PRBC.History of Present Illness:This is a 80yo woman with h/o CAD s/p cypher DES to LCX [**2174-5-13**]and recent aortic valvuloplasty [**2174-5-11**] recently hospitalizedfor
CHF
DISEASE
exacerbation requiring intubation(d/c [**2174-7-4**]) whoreturns w/SOB x several hours. She notes that she had beenfeeling well since her d/c home until this AM. She awoke at 0300feeling well but then began to get aggravated thinking aboutrecent political issues and started to feel SOB as she sat inbed. Endorses slow onset SOB that persisted causing her and herhusband to call EMS. She received one dose of IV lasix 100mg enroute to the ED to which she put out
100cc
DISEASE
of urine. Sheendorses having had
cough
DISEASE
w/sputum production 2 days PTA butdenies recent fever/chills..In the ED her initial VS were: 96.4 174/82 HR 109 RR 30s sat85% 10LNRB. She was briefly on CPAP 5/5 and O2 sat increased to100%. She was also briefly on a Nitroglycerin drip for herBP(1hour). She received Aspirin Furosemide 180mg IV x1 as wellas Vancomycin 1g and Piperacillin-Tazobactam for her
leukocytosis
DISEASE
..She and her husband endorse that she has been adherent with hermedications and her 2g sodium diet w/1200-1500 fluidrestriction. They note that her daily weight has been very closeto her dry weight of 109lbs w/just one higher weight last weekof 109.5lbs. She denies
chest pain
DISEASE
ankle
edema palpitations
DISEASE
syncope
DISEASE
or
presyncope
DISEASE
. Admission Date: [**2174-7-22**] Discharge Date: [**2174-8-5**]Date of Birth: [**2093-11-17**] Sex: FService: MEDICINE
Allergies
DISEASE
:AtorvastatinAttending:[**First Name3 (LF) 458**]Chief Complaint:
Shortness of breath
DISEASE
Major Surgical or Invasive Procedure:upper endoscopy dialysisHistory of Present Illness:This is a 80yo woman with h/o CAD s/p cypher DES to LCX [**2174-5-13**]and recent aortic valvuloplasty [**2174-5-11**] s/p multiplehospitalizations for
CHF
DISEASE
exacerbation (last d/c [**2174-7-20**]) whoreturns w/SOB x several hours. Her husband noted that she wenthome feeling well. She was breathing comfortably w/o anyepisodes of CP/palpitations/SOB. This AM Admission Date: [**2174-8-6**] Discharge Date: [**2174-8-12**]Date of Birth: [**2093-11-17**] Sex: FService: MEDICINE
Allergies
DISEASE
:AtorvastatinAttending:[**First Name3 (LF) 458**]Chief Complaint:
Shortness of breath
DISEASE
Major Surgical or Invasive Procedure:DialysisHistory of Present Illness:Pt is a 80 yo woman with h/o CAD s/p cypher DES to LCX [**2174-5-13**]severe
aortic stenosis
DISEASE
with valvular area of 0.5 cm2 despiterecent aortic valvuloplasty on [**2174-5-11**] frequenthospitalizations for
CHF
DISEASE
exacerbation (last d/c [**2174-8-5**]) and
ESRD
DISEASE
recently restarted on HD who returns w/SOB. She wasadmitted on [**2174-7-22**] for
CHF
DISEASE
exacerbation and dischargedyesterday. She was initally treated with Lasix went intoworsening
renal failure
DISEASE
and started on hemodialysis. Her coursewas also complicated by upper GI bleed of which an EGD showedmultiple AVMs. She required total of 5 units of PRBCs and bydischarge HCT was stable at 26. She received her lasttransfusion yesterday at HD.Pt was discharged to rehab. She ate well for dinner under 2 gmof sodium diet. She report feeling warm the evening prior toadmission but was afebrile. She still felt warm and diaphoreticthis morning. Again she was afebrile per her husband. She didhave increased productive
cough
DISEASE
with mostly clear occasionally
blood-tinged phlegm
DISEASE
. She then became acutely short of breathwhile lying down. She denied any
CP palpitations nausea
DISEASE
vomiting
DISEASE
. She asked to return to the hospital..In the ED her initial VS were: T98 BP 150/80 HR 130 RR 42O2 sat 92% on Admission Date: [**2141-8-16**] Discharge Date: [**2141-8-24**]Date of Birth: [**2070-10-21**] Sex: FService: SURGERY
Allergies
DISEASE
:Hydrochlorothiazide / ZoloftAttending:[**First Name3 (LF) 473**]Chief Complaint:Pancreatic Head Mass / CBD MassMajor Surgical or Invasive Procedure:Pylorus-Preserving Whipple ProcedureOpen Cholecystectomy
Primary Incisional Hernia
DISEASE
RepairHistory of Present Illness:This is a 70 year old female with a history of
ovarian cancer
DISEASE
now with 2 weeks of painless
jaundice
DISEASE
dark urine acholicstools and she was found to have a distal CBD/pancreatic headmass on CT and ERCP.Past Medical History:PMHx: ovarian CA
HTN
DISEASE
high chol AAA (3.5 cm)
OA
DISEASE
CRI (CR 1.5)PSHx: TAH/BSO [**2126**]Admission Date: [**2143-4-20**] Discharge Date: [**2143-4-26**]Date of Birth: [**2070-10-21**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:Hydrochlorothiazide / Zoloft / CompazineAttending:[**First Name3 (LF) 492**]Chief Complaint:SOBMajor Surgical or Invasive Procedure:L thoracotomy with pericardial window and chest tube placementHistory of Present Illness:72 W from [**First Name8 (NamePattern2) 466**] [**Country 467**] with
multiple cancers
DISEASE
including ovarian(s/p s/p TAH SBO and 6 cycles of ctaxol/carboplatinium) and
cholangiocarcinoma
DISEASE
(s/p whipple) with
mets
DISEASE
of uncertain originto
liver and lung
DISEASE
recently admitted [**4-6**]-22 for CAP(treated with azithro) originally admitted to [**Hospital Unit Name 153**] for SOB
orthopnea
DISEASE
and coughing which was initially attributed to
CHF
DISEASE
symptomatic
hyponatremia
DISEASE
(increasing
confusion
DISEASE
lethary) and
ARF
DISEASE
. Cards was consulted and an echocardiogram revealed apericardial fluid collection with
tamponade
DISEASE
. She was senturgently to the OR for a pericardial window via L thoracotomy.She was out of the OR by [**8-28**] PM extubated by 0400 the day oftransfer and seemed to be doing well. She was sitting up in achair when she was noticed to be unresponsive but stillbreathing and with a pulse. She was transferred back to her bedand at that ppint was noticed to be in full cardiac and
respiratory arrest
DISEASE
without pulse or spontaneous respirations.Patient did have a rhythm on monitor so patient was diagnosedwith
PEA arrest
DISEASE
. CPR was initiated she received 2 amps of epiand an an of calium she was intubated started on Neo and hada femoral line placed. Within 15 minutes pulse returned. Astat repeat ECHO was performed at that time and patient wasfound to have [**Male First Name (un) **] (systolic anterior motion) severe
MR
DISEASE
and new
wall motion abnormalities
DISEASE
but no re-accumulation of pericardialeffusion. She is now being transferred to the MICU for furtherwork-up and management.Past Medical History:
Pancreatic cancer
DISEASE
s/p whipple [**2141-7-18**] metastatic to liverOvarian ca s/p carboplatinum/taxol ([**2126**])
HTN
DISEASE
AAA
OA
DISEASE
Depression
DISEASE
Vertigo
DISEASE
Social History:Occupation: former storekeeper in [**First Name8 (NamePattern2) 466**] [**Country 467**] moved to US in[**2134**] after husband disappeared during their pilgrimage to [**Location (un) 481**]in [**2133**]Drugs: NoneTobacco: NoneAlcohol: NoneFamily History:NCPhysical Exam:General Appearance: ThinEyes / Conjunctiva: PERRL Conjunctiva paleHead Ears Nose Throat: Normocephalic dry MMLymphatic: Cervical LADCardiovascular: (PMI Normal) (S1: Normal) (S2: Normal)(Murmur: [**1-23**] soft Systolic Ejection Murmur)Peripheral Vascular: (Right radial pulse: Present) (Left radialpulse: Present) (Right DP pulse: Present) (Left DP pulse:Present)Respiratory / Chest: (Expansion: Symmetric) (Breath Sounds:Crackles : [**12-19**] way up bilaterally)Abdominal: Soft
Non-tender No bowel sounds
DISEASE
present nontender
palpaple mass
DISEASE
in epigastriumExtremities: Right: 2Admission Date: [**2143-4-25**] Discharge Date: [**2143-4-30**]Date of Birth: [**2076-8-18**] Sex: MService: Cardiac SurgeryCHIEF COMPLAINT:
Chest pain
DISEASE
3-vessel disease oncatheterization.HISTORY OF PRESENT ILLNESS: The patient is a 66-year-oldmale transferred from [**Hospital6 33**] to the [**Hospital1 346**] status post catheterizationrevealing 3-vessel
cardiac disease
DISEASE
.The patient presented to [**Hospital6 33**] with graduallyincreasing
chest pain
DISEASE
over the past three to four months tothe point that he had
chest pain
DISEASE
with minimal exertion.PAST MEDICAL HISTORY:1. Known
coronary artery disease
DISEASE
status postcatheterization 10 years ago at [**Hospital1 **].2. Heavy smoker.3.
Hypertension
DISEASE
.4.
Gastroesophageal reflux disease/peptic ulcer disease
DISEASE
.5.
Wegener granulomatosis
DISEASE
with complete resolution.6. Glaucoma.PAST SURGICAL HISTORY: Perforated
ulcer
DISEASE
.MEDICATIONS ON ADMISSION: Lisinopril 20 mg p.o. q.d.Prilosec 20 mg p.o. q.d. Cosopt eyedrops Alphagan eyedropsTravatan eyedrops lansoprazole 50 mg p.o. q.d.ALLERGIES: No known
drug allergies
DISEASE
.HOSPITAL COURSE: The patient underwent an elective coronaryartery bypass graft times three on [**2143-4-26**] with graftsbeing a left internal mammary artery to left anteriordescending artery saphenous vein graft to ramus andsaphenous vein graft to posterior descending artery. He wasextubated on the day of surgery. On postoperative day onehis nasogastric tubes were discontinued.He was transferred to the regular floor on postoperative dayone. He subsequently had a smooth postoperative course. Hispacing wires were discontinued on postoperative day three.By postoperative day he was ambulating well. He wascomfortable on p.o.
pain
DISEASE
medication and he was ready fordischarge home.MEDICATIONS ON DISCHARGE:1. Lasix 20 mg p.o. q.d. (for one week).2. KCL 20 mEq p.o. q.d. (for one week).3. Colace 100 mg p.o. b.i.d.4. Zantac 150 mg p.o. b.i.d.5. Enteric-coated aspirin 325 mg p.o. q.d.6. Alphagan eyedrops.7. Lopressor 50 mg p.o. b.i.d.8. Nicoderm patch 22 mg q.d.9. Percocet one to two tablets p.o. q.4-6h. p.r.n.DI[**Last Name (STitle) 408**]E FOLLOWUP: Follow up with primary care physician[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2208**] in two weeks and with Dr. [**Last Name (Prefixes) **] infour weeks.CONDITION AT DISCHARGE: Condition on discharge was stable.DISCHARGE STATUS: Discharged to home. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**] M.D. [**MD Number(1) 414**]Dictated By:[**Last Name (NamePattern1) 2209**]MEDQUIST36D: [**2143-4-30**] 15:09T: [**2143-4-30**] 15:31JOB#: [**Job Number 2210**]Admission Date: [**2189-9-7**] Discharge Date: [**2189-9-9**]Date of Birth: [**2129-3-28**] Sex: FService: MEDICINE
Allergies
DISEASE
:LomotilAttending:[**Last Name (NamePattern1) 495**]Chief Complaint:
Pyelonephritis
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:Ms. [**Known lastname 496**] is a 60 yo F with hx of chronic hepatitis C whopresents to the ED with
dysuria
DISEASE
x 4 days
chills nausea
DISEASE
and
vomiting
DISEASE
. She first noted
hematuria
DISEASE
on Saturday then developed
dysuria
DISEASE
urinary frequency urgency and
incontinence
DISEASE
. Admission Date: [**2112-6-6**] Discharge Date: [**2112-6-14**]Service: GENERAL SURGERYHISTORY OF PRESENT ILLNESS: On [**2112-6-5**] the patient had asudden onset of
emesis
DISEASE
in the morning with no associated
nausea abdominal pain
DISEASE
or change in bowel habits and ispassing flatus. She also passed brown stool that day. Shehas had no signs of
fevers
DISEASE
or
chills
DISEASE
or sick contacts orrecent travel. Twenty years ago the patient had a similarepisode and by history she was told she had a gallbladderproblem but she never had any treatment given. Shepresented to the Emergency Department with a
fever
DISEASE
of 104.4and mildly tender right upper quadrant with negative [**Doctor Last Name 515**]sign. An ultrasound demonstrated multiple gallbladder stonesand a 1.4 cm stone in a 1.5 cm common bile duct. No
intrahepatic ductal dilatation or gallbladder wall thickening
DISEASE
or pericholecystic fluid. The patient received Levofloxacinand Flagyl and was urgently seen by the ERCP fellow and takenfor endoscopic retrograde cholangiopancreatography whichdemonstrated some
gastritis
DISEASE
and severely deformed majorpapilla and 8 mm common bile duct with no stones and asphincterotomy was performed with drainage of clear bile.The patient was then admitted to the Medical Service.PAST MEDICAL HISTORY: 1. Hypertension. 2.
Breast cancer
DISEASE
status post lumpectomy in [**2103**]. 3. Hypercholesterolemia.4.
Diabetes mellitus
DISEASE
type 2. 5. Hypothyroidism status postthyroidectomy. 6. Left
cataract
DISEASE
surgery cornealtransplant. 7. Pernicious
anemia
DISEASE
. 8. Stress
incontinence
DISEASE
.9. Appendectomy.ALLERGIES: Bactrim.MEDICATIONS: 1. Atenolol 50 mg po q day. 2. Glyburide.3. Mavic one time per day. 4. Synthroid 150 mg po q day.5. Lipitor 10 mg po q day. 6. Aspirin 81 mg po q day. 7.Apraclonidine 0.5% one drop OS b.i.d. 8. Timolol maleate0.5% one drop OS b.i.d. 9. Prednisolone acetate one drop OSt.i.d.SOCIAL HISTORY: The is a Russian immigrant who taughtEnglish. The patient does not use tobacco or alcohol.PHYSICAL EXAMINATION: The patient had a temperature of100.6 heart rate of 62 blood pressure 153/60 respiratoryrate 22 saturation 92% on room air. Pertinent physicalexamination demonstrated a soft mildly tender right upperquadrant with no [**Doctor Last Name **] sign. Normal rectal tone and guaiacnegative.PERTINENT LABORATORY INFORMATION: White blood cell count4.4 PT 13.7 INR 1.3 total bilirubin was 0.4 ALT 34 AST24 alkaline phosphatase 106. Urinalysis negative.HOSPITAL COURSE: The patient was managed medically until the[**4-10**] because the patient was refusingcholecystectomy as was recommended. However on the [**4-10**] the patient was amenable to surgery because ofpersistent right upper quadrant soreness. On [**6-10**] thepatient underwent an open cholecystectomy with a common bileduct exploration and placement of T tube and intraoperativecholangiogram. The patient had some difficulty withextubation because of sedation and was transferred from the[**Hospital Ward Name 516**] at [**Hospital1 69**] to the[**Hospital Ward Name 517**] in the Surgical Intensive Care Unit. Thefollowing day on postoperative day one the patient wasextubated after being weaned off her Propofol without anycomplications and was maintained NPO. The patient remainedwell throughout the afternoon in the Surgical Intensive CareUnit and was transferred to the floor.On the floor the patient did well. Physical therapy consultwas acquired where she performed well but was recommendedfor rehabilitation. She began tolerating clears and aregular diet. She remained afebrile and she had her Foleydiscontinued. The patient had her JP tube discontinued andwas appropriate for rehab by postoperative day four [**2112-6-14**].The patient will follow up with Dr. [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 519**] in twoweeks and during the same visit had a T tube cholangiogramperformed prior to seeing Dr. [**Last Name (STitle) 519**]. The patient will also goto rehab for further physical therapy rehabilitation andmedical care. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] M.D. [**MD Number(1) 521**]Dictated By:[**Name8 (MD) 522**]MEDQUIST36D: [**2112-6-14**] 10:25T: [**2112-6-14**] 10:37JOB#: [**Job Number 523**]Admission Date: [**2112-7-2**] Discharge Date: [**2112-7-11**]Service: GREEN GENERAL SURGERYHISTORY OF PRESENT ILLNESS: This 81-year-old elderly ladyunderwent an open cholecystectomy and common bile ductexploration for type I
Mirizzi syndrome
DISEASE
three weeks prior toadmission. On [**2112-7-1**] one day prior to admissionshe had a normal T-tube cholangiogram without antibioticcoverage. She was seen by Dr. [**Last Name (STitle) 519**] in his office andapproximately two hours later removed the T-tube withoutincident. After the removal of the tube the patientdeveloped progressive
nausea
DISEASE
and
chills
DISEASE
and right sided
abdominal pain
DISEASE
as reported by her daughter. She presented tothe [**Hospital6 256**] Emergency Department
hypotensive
DISEASE
to 80s systolic and acidotic leading tointubation and institution of pressor support. Her whitecount at the time of admission was 12 with a total bilirubinof 3.6. AST and ALT were both above 500 with an alkalinephosphatase of 334. Her amylase and lipase were both in thenormal range.On examination at the time of admission Mrs. [**Known firstname 524**][**Name (STitle) 525**] abdomen was soft with mild right upper quadrantguarding. CT examination showed no collection and a mildly
dilated common bile duct
DISEASE
. Ascending
cholangitis
DISEASE
secondary toseeding at the time of cholangiogram with
stricture
DISEASE
at theT-tube site with or without a retained stone was thediagnosis.PAST MEDICAL HISTORY:1.
Hypertension
DISEASE
2.
Breast cancer
DISEASE
3. High cholesterol4.
Diabetes mellitus
DISEASE
5. Hypothyroidism6. Multinodular
goiter
DISEASE
PAST SURGICAL HISTORY: Breast lumpectomy in [**2103**] and athyroidectomy in [**2106**].HOME MEDICATIONS:1. Atenolol2. Glyburide3. Synthroid4. Lipitor5. ASAHOSPITAL COURSE: On [**2112-7-3**] Mrs. [**Known lastname 526**] wasadmitted to the Surgical Intensive Care Unit for closemanagement of her respiratory cardiovascular and infectiousstatus. She was seen by the ERCP service/fellow and shereceived an emergency MRCP for ascending
cholangitis
DISEASE
. Thisstudy showed altered
papilla anatomy dilated common bile
duct
DISEASE
and question of common
hepatic duct stricture
DISEASE
. Therewas no small leak at the site of the cystic duct/T-tubetrack. The ERCP resulted in 10 cc of purulent aspirate and a10 French x 8 cm stent was placed. After this procedureMrs. [**Known lastname 526**] continued to be monitored closely in theIntensive Care Unit where her cardiovascular status wasmonitored using a Swan-Ganz catheter.By hospital day #3 Mrs. [**Known lastname 526**] was showing clinicalimprovement from her ascending
cholangitis
DISEASE
. On this day shestarted to wean off the ventilator and her white countdeclined to 5.7. The rest of Mrs.[**Known lastname 527**] SurgicalIntensive Care Unit course was characterized by progressiveweaning from the ventilators and from dobutamine and othermedications used to support her cardiovascular status.Intravenous antibiotics consisting of Flagyl ceftriaxone andampicillin were continued. The patient was extubated on [**7-7**] and on [**2112-7-9**] she was transferred to thepatient floor out of the Intensive Care Unit and placed onLevaquin. Her status continued to stabilize and improve onthe floor and her condition at the time of discharge was verygood.DISCHARGE STATUS: Very goodDISCHARGE DIAGNOSIS: Ascending
cholangitis
DISEASE
Per consultation with the physical therapy service dischargeof the patient to a rehabilitation center was suggested asthe patient lived alone and would not be able to at the timeof discharge successfully complete all of her necessaryactivities of daily life.FOLLOW UP PLANS: Dr. [**Last Name (STitle) 519**] and this should be done in twoweeks after discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] M.D. [**MD Number(1) 521**]Dictated By:[**Last Name (NamePattern1) 528**]MEDQUIST36D: [**2112-7-11**] 10:36T: [**2112-7-11**] 10:55JOB#: [**Job Number 529**]Admission Date: [**2119-4-6**] Discharge Date: [**2119-4-15**]
Service: MEDICINE
Allergies
DISEASE
:Bactrim Ds / Zyprexa / LisinoprilAttending:[**First Name3 (LF) 552**]Chief Complaint:Altered Mental StatusMajor Surgical or Invasive Procedure:CT headMRI/MRALPLarynoscopyHistory of Present Illness:HPI: The patient is an 88 year old female resident at [**First Name5 (NamePattern1) 553**][**Last Name (NamePattern1) 554**] [**Hospital3 **] with medical history pertinent for
Parkinson's disease Diabetes
DISEASE
and recent cornea transplant whonow presents with altered mental status.Per last progress note from patient's PCP [**Name10 (NameIs) **] patient has beenin her usual state of health with exception of management of a
cervical vertebral fracture
DISEASE
secondary to fall as well as plansfor a repat penetrating keratoplasty (corneal transplant) s/pfailed prior. The patient was at that time apparently at herbaseline and cleared for surgery. The patient underwentpenetrating keratoplasty on [**2119-3-30**] for indication of failedgraft without complication. The patient was seen by herophthalmologist on [**2119-4-4**] with impression that there wasmoderate
lid edema
DISEASE
present suggestive of
hypersensitivity
DISEASE
but nodischarge to suggest
infection
DISEASE
. Polysporin was discontinued(with concern for hypersensitivty per discussion with daughter)and other meds (Pred 1% TID OS Timolol 0.5% [**Hospital1 **] OU Xalatan QHSOS Tobradex[**Doctor Last Name **] OS QHS) continued.The patient now presents form her [**Hospital3 **] with concernfor altered mental status. Only limited information is availablefrom available staff at [**Hospital3 400**] with report only thatpatient was noted tonight to be acutely confused and Admission Date: [**2141-7-4**] Discharge Date: [**2141-7-10**]Service: GUHISTORY OF PRESENT ILLNESS: The patient was admitted on [**2141-7-4**] for a left nephrectomy and periaortic lymph nodedissection and cystoscopy secondary to diagnosis of
transitional carcinoma
DISEASE
and a
left renal mass
DISEASE
. She was firstseen by Dr. [**Last Name (STitle) **] on [**2141-5-12**] for an evaluation of anepisode of gross
hematuria
DISEASE
that was associated with anenhancing soft tissue mass in the upper pole of theinfundibulum of the left kidney. This was diagnosed by CT on[**2141-5-9**]. Now was confirmed by MRI and measured to be3.3 cm. The patient was then scheduled for a left nephrectomyand staging studies revealed that the right kidney was OK.She has no history of
UTIs colon cancer smoking
DISEASE
or
dysuria
DISEASE
.However there is a positive family history for renal cell
cancer
DISEASE
in her brother who is currently affected.ALLERGIES: She reports no known
drug allergies
DISEASE
.MEDICATIONS: Outpatient medications include LipitorNorvasc vitamins and aspirin.PAST MEDICAL HISTORY: Significant for questionable
TIA
DISEASE
whichgave her temporary
memory loss
DISEASE
. Her past medical history isnegative for a
MI angina diabetes colitis COPD
DISEASE
or any
thyroid disease
DISEASE
.PAST SURGICAL HISTORY: Repair of a tendon in her right handin the remote past.SOCIAL HISTORY: No tobacco and no drug use but alcohol useabout 4 times a week.FAMILY HISTORY: Significant for a brother with renal cell
carcinoma
DISEASE
.PHYSICAL EXAMINATION: Vital signs: Afebrile vital signsstable. General: She appears well and sitting comfortably.HEENT: No masses. Chest: Clear to auscultation bilaterally.CV: Normal sinus rhythm. Abdomen soft nontendernondistended.HOSPITAL COURSE: She was admitted to the SICU on [**2141-7-4**] after her left nephrectomy periaortic lymph nodedissection and cystoscopy. She did well postoperativelyunderwent no events in the SICU and was transferred to theregular floor the following day on [**2141-7-5**]. She did wellon the floor. Her
pain
DISEASE
was well controlled and she was alsogiven Ancef for 3 doses. Chest x-ray in the SICU showed a 5mm
pneumothorax
DISEASE
but the chest tube was pulled. The repeatchest x-ray performed upon arrival to the floor was negativefor a
pneumothorax
DISEASE
. On [**2141-7-6**] postoperative day 2 thepatient continued to improve. She began to ambulate. Her NGtube was discontinued. She was taken off telemetry. Yet shepassed no gas there was no flatus. Postoperative day 3 shecontinued to improve and she continued to ambulate and stillawaiting return of bowel function. Postoperative day 4 herabdomen was distended slightly tympanitic. She was returnedto NPO encouraged to ambulate given PCA for her
pain
DISEASE
control and the results of her abdominal film were pending.Her abdominal film came back negative. On [**7-9**]postoperative day 5 she continued to do well and her dietwas advanced as tolerated after she passed gas and ambulationwas encouraged. Postoperative day 6 [**2141-7-10**] thepatient did very well in her whole hospital course was doingwell in the morning and was discharged that evening. She wasgiven instructions to follow-up with Dr. [**Last Name (STitle) **] as well asappropriate
pain
DISEASE
medication and Colace.INPATIENT MEDICATIONS: Inpatient medications include Milk ofMagnesia 30 ml p.o. q.8 hours docusate sodium 100 mg p.o.b.i.d. morphine sulfate 1.5 mg via PCA potassium chloride20 mEq and 250 of saline sliding scale insulin amlodipine2.5 mg p.o. daily famotidine 20 mg p.o. q.24 hourspantoprazole 40 mg p.o. q.24 hours a liter of normal salineat 80 ml/hour acetaminophen 325 to 650 mg p.o. q.4-6 hoursp.r.n.
fever
DISEASE
or
pain
DISEASE
atorvastatin 10 mg p.o. daily. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **] [**MD Number(1) 559**]Dictated By:[**Name8 (MD) 560**]MEDQUIST36D: [**2141-8-17**] 12:37:49T: [**2141-8-17**] 14:44:38Job#: [**Job Number 561**]Admission Date: [**2102-6-12**] Discharge Date: [**2102-6-16**]Date of Birth: [**2044-7-15**] Sex: MService: MEDICINE
Allergies
DISEASE
:Bactrim / Hismanal / IodineAdmission Date: [**2118-7-10**] Discharge Date: [**2118-7-11**]Date of Birth: [**2034-1-26**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 594**]Chief Complaint:Respiratory DistressMajor Surgical or Invasive Procedure:BiPAPHistory of Present Illness:84M PMhx metastatic papillary thyroid CA (s/p resectionradioactive iodine)
c/b lung mets
DISEASE
found to have large cavitarymass in RLL recent admission with
malignant effusion
DISEASE
Admission Date: [**2101-8-15**] Discharge Date: [**2101-8-29**]Service: SURGERY
Allergies
DISEASE
:Demerol / Shellfish Derived / AspirinAttending:[**First Name3 (LF) 598**]Chief Complaint:
nausea vomiting abdominal distention
DISEASE
Major Surgical or Invasive Procedure:[**2101-8-16**]Exploratory laparotomyHistory of Present Illness:Pt is [**Age over 90 **] y/o F with h/o
COPD
DISEASE
who presents with 3 day h/onausea/vomiting and
abdominal distension
DISEASE
. Pt states that she ishaving
emesis
DISEASE
of whatever she ingests and has not had a bowelmovement in the past 3 days. Pt states that she is not havingmuch
abdominal pain
DISEASE
. No
fevers
DISEASE
or
chills
DISEASE
.Past Medical History:PMH:1.
Rheumatoid arthritis
DISEASE
.2.
Osteoporosis
DISEASE
3. Macular degeneration.4.
Hyperparathyroidism
DISEASE
.5.
Hypothyroidism
DISEASE
.6.
Mitral regurgitation
DISEASE
.7.
COPD
DISEASE
.8. Kyphoscoliosis.9. Chronic lower extremity edema.
PSH
DISEASE
: noneSocial History:lives with husband no etoh or tobaccoFamily History:non contributoryPhysical Exam:Temp 98.6 P 94 BP 128/61 R 24 SaO2 96% 2LGen: no acute distressHeent: no scleral icterusNeck: suppleLungs: clearHeart: regular rate and rhythmAbd: soft distended nontender no guarding nonrigidAdmission Date: [**2101-11-1**] Discharge Date: [**2101-11-10**]Service: MEDICINE
Allergies
DISEASE
:Demerol / Shellfish Derived / AspirinAttending:[**First Name3 (LF) 602**]Chief Complaint:
hypercarbic respiratory failure
DISEASE
Major Surgical or Invasive Procedure:Intubation [**2101-11-1**]A line insertion [**2101-11-2**]PICC line [**2101-11-2**]History of Present Illness:[**Age over 90 **]F w/hx of
COPD
DISEASE
on 2L at baseline for last day has had increaseO2 requirement. Per husband/rehab has increased O2 requirementover the last day.
Coughing
DISEASE
decreased from
COPD
DISEASE
baseline. Yestwas hypoxic and NC uptitrated to 5L. This AM requiring NRB (satsand circumstances unclear). [**Name2 (NI) **] has been afebrile but hashad increasing LE
edema
DISEASE
.Per husbands report had not been on home O2 for
COPD
DISEASE
untilplaced in rehab in [**Month (only) 205**]. Had been living at home and veryfunctional until recent admission in [**Month (only) 205**] for
N/V/Abd
DISEASE
distension. Had a laparotomy and appendix taken and out R
femoral hernia
DISEASE
repaired. D/ced to rehab and has been theresince. Husband reports that roughly a week ago she had aworsening
cough
DISEASE
and he thought she had developed
bronchitis
DISEASE
.From the rehab charts it appears she was put on a prednisonetaper and azithromycin. He reports she had been improving withthese treatments until the last 2 days although his history ofher worsening is very unclear. [**Name2 (NI) **] ED signout from talking tothe nursing home she was more hypoxic yesterday requiring 5L NCand being placed on a NRB this AM. He reports she wascomplaining of no other symptoms but is unclear if there was anychange in her mental status.He reports that at home baseline before rehab she was able totalk roughly 50yds before being limited by
shortness of breath
DISEASE
.She did all the chores cooking and cleaning at the house perhis report and they went out together 3x/week. Since heradmission to the hospital and discharge to rehab he reports shehad not done as well but again his history is somewhat unclear.ED Course presented with Temp 98.4 HR 96 BP 118/54 RR 44Sats 100% on
NRB
DISEASE
. Altered here A&O x 1 husband (also in 90s)says she is fine at rehab baseline. Rales bilateral bases withJVD at mandible. CXR showed bilateral
pleural effusions
DISEASE
withinfiltrated on RLQ and concern for aspiration. WBC elevated to17.3 (89% PMNs without bands Bcx drawn and started onvanco/zosyn. EKG: NSR at 94 NA/NI No ST elevations. Givencombivent trial with 125mg IV methlyprednisone. Initial Chem 7with HCO3 of 42 BNP of 1700. Initial VBG on NRB showed 7.23 /112 / 55 / 49. Trialed on BiPAP with ABG showing 7.18 / 138 /209 / 54. Pt wasn't tolerating BiPAP and kept taking off. Resprate high but other VSS. ED called PCP and daughter as pt hadDNR order but no DNI order and husband wanting everything done.Daughter and PCP decided to intubate and see how things go withthought that would withdraw care if dosen't recover. Easyintubation. Intubated with succinylcholine and propofol. Afterintubation and propofol BPs dropped to 80s/60s given 1L NS andswitched to Midazolam and Fentanyl. Did not require pressors andBPs came up to 110-120s. No CVL placed (2 PIV). Yellowish fluidfrom lungs after intubation (unclear when was aspirating - withintubation vs yest).VS on ICU arrival now: Afebrile BP 106/51 HR 81 RR 20 98% on100% FiO2 on Vent. Pt unable to respond to questioning and so noROS could be obtained.Past Medical History:PMH:1.
Rheumatoid arthritis
DISEASE
.2.
Osteoporosis
DISEASE
3. Macular degeneration.4.
Hyperparathyroidism
DISEASE
.5.
Hypothyroidism
DISEASE
.6.
Mitral regurgitation
DISEASE
.7.
COPD
DISEASE
.8. Kyphoscoliosis.9. Chronic lower extremity edema.
PSH
DISEASE
: noneSocial History:At rehab since
hernia
DISEASE
and appendectomy surgery [**8-15**]. no etoh ortobaccoFamily History:No family history of
pulmonary disease
DISEASE
or
clotting disorders
DISEASE
.Physical Exam:Admission physical exam:Vitals: T: 98.5 BP: 141/56 P: 88 R: 18 O2: 100% on 100% FiO2General: Opens eyse to voice intubatedHEENT: Sclera anicteric
dry MM
DISEASE
Neck: supple no LAD no JVP elevationLungs: Diffuse ronchi bilaterally with decreased air movementCV: RR with occasional ectopic beats normal S1 Admission Date: [**2191-5-9**] Discharge Date: [**2191-5-14**]Date of Birth: [**2108-6-9**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 603**]Chief Complaint:
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:82 year old male with
HTN
DISEASE
chronic
CHF
DISEASE
and
COPD
DISEASE
BIBA afterdeveloping SOB. Pt has noted increasing SOB on exertion over thepast week. Has also noted occasional episodes of
diarrhea
DISEASE
andrare short bouts of
chest pain
DISEASE
. Increasing DOE on exertionyesterday. Today walked to his car and was so short of breath heleaned on the [**Doctor Last Name 534**] to attract attention for help. A neighborcame and found him and called an ambulance..Of note pt was also admitted [**2190-1-30**] for SOB c/w
CHF
DISEASE
exacerbation responded to lasix..When EMS arrived they noted his BP to be 200/100..In the ED inital vitals were HR: 100 BP: 134/109 Resp: 34O(2)Sat: 92 (CPAP)low. Labs showed CBC 8.2Admission Date: [**2143-4-25**] Discharge Date: [**2143-4-30**]Date of Birth: [**2076-8-18**] Sex: MService: Cardiac SurgeryCHIEF COMPLAINT:
Chest pain
DISEASE
3-vessel disease oncatheterization.HISTORY OF PRESENT ILLNESS: The patient is a 66-year-oldmale transferred from [**Hospital6 33**] to the [**Hospital1 346**] status post catheterizationrevealing 3-vessel
cardiac disease
DISEASE
.The patient presented to [**Hospital6 33**] with graduallyincreasing
chest pain
DISEASE
over the past three to four months tothe point that he had
chest pain
DISEASE
with minimal exertion.PAST MEDICAL HISTORY:1. Known
coronary artery disease
DISEASE
status postcatheterization 10 years ago at [**Hospital1 **].2. Heavy smoker.3.
Hypertension
DISEASE
.4.
Gastroesophageal reflux disease/peptic ulcer disease
DISEASE
.5.
Wegener granulomatosis
DISEASE
with complete resolution.6. Glaucoma.PAST SURGICAL HISTORY: Perforated
ulcer
DISEASE
.MEDICATIONS ON ADMISSION: Lisinopril 20 mg p.o. q.d.Prilosec 20 mg p.o. q.d. Cosopt eyedrops Alphagan eyedropsTravatan eyedrops lansoprazole 50 mg p.o. q.d.ALLERGIES: No known
drug allergies
DISEASE
.HOSPITAL COURSE: The patient underwent an elective coronaryartery bypass graft times three on [**2143-4-26**] with graftsbeing a left internal mammary artery to left anteriordescending artery saphenous vein graft to ramus andsaphenous vein graft to posterior descending artery. He wasextubated on the day of surgery. On postoperative day onehis nasogastric tubes were discontinued.He was transferred to the regular floor on postoperative dayone. He subsequently had a smooth postoperative course. Hispacing wires were discontinued on postoperative day three.By postoperative day he was ambulating well. He wascomfortable on p.o.
pain
DISEASE
medication and he was ready fordischarge home.MEDICATIONS ON DISCHARGE:1. Lasix 20 mg p.o. q.d. (for one week).2. KCL 20 mEq p.o. q.d. (for one week).3. Colace 100 mg p.o. b.i.d.4. Zantac 150 mg p.o. b.i.d.5. Enteric-coated aspirin 325 mg p.o. q.d.6. Alphagan eyedrops.7. Lopressor 50 mg p.o. b.i.d.8. Nicoderm patch 22 mg q.d.9. Percocet one to two tablets p.o. q.4-6h. p.r.n.DI[**Last Name (STitle) 408**]E FOLLOWUP: Follow up with primary care physician[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2208**] in two weeks and with Dr. [**Last Name (Prefixes) **] infour weeks.CONDITION AT DISCHARGE: Condition on discharge was stable.DISCHARGE STATUS: Discharged to home. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**] M.D. [**MD Number(1) 414**]Dictated By:[**Last Name (NamePattern1) 2209**]MEDQUIST36D: [**2143-4-30**] 15:09T: [**2143-4-30**] 15:31JOB#: [**Job Number 2211**]Admission Date: [**2158-2-14**] Discharge Date: [**2158-3-6**]Service: NEUROLOGY
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 618**]Chief Complaint:transferred for
seizures
DISEASE
Major Surgical or Invasive Procedure:intubationHistory of Present Illness:86y M with PMH significant for
HTN
DISEASE
CAD s/p CABG afib (now onwarfarin)
stroke
DISEASE
2y ago and a
seizure disorder
DISEASE
on Keppra(previously seen in clinic by Dr. [**Last Name (STitle) 619**]. atrial
fibrillation
DISEASE
on Coumadin. who presents with left ear
pain
DISEASE
. Hepresented to the OSH ED ([**Hospital1 **]-[**Location (un) 620**]) 1wk PTA with CC: ear
pain
DISEASE
.He was sent home with Dx of cerumen in external canal. His ear
pain
DISEASE
continued and this past Friday his PCP prescribed [**Name9 (PRE) 621**] gttfor presumed
otitis
DISEASE
externa. Per his son he developedprogressive
confusion
DISEASE
and imbalance. He became unable to walkand became more somnolent.He returned to the ED at [**Hospital1 **]-[**Location (un) 620**] in the evening of [**2158-2-13**](1dprior to transfer here) where his VS were notable for
fever
DISEASE
to102.2F (after arriving afebrile) and
tachycardia
DISEASE
(normalizedwith1.5 L IVF) and exam was notable for
somnolence
DISEASE
. His WBC waselevated at 14.9. INR was 3.3. Dig 0.84. Troponin negative. UAAdmission Date: [**2189-8-5**] Discharge Date: [**2189-8-11**]Date of Birth: [**2142-2-22**] Sex: FService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 633**]Chief Complaint:
nausea
DISEASE
and
vomiting
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Ms. [**Known lastname 634**] is a 47 year old female with past medical historyof
hypothyrodism
DISEASE
who was doing well until yesterday. She hadthree episodes of
nonbloody emesis
DISEASE
followed by fourth episode at8 am with streak of blood. She did well throughout the dayuntil 6 pm when she had one cup full of
hematemesis
DISEASE
leading herto present to the ED.In the ED initial vitals were HR 66 and BP 121/72. She had [**1-5**]cup of
hematemesis
DISEASE
in the ED. Nasogastric lavage returned Admission Date: [**2125-2-13**] Discharge Date: [**2125-2-22**]Date of Birth: [**2062-5-2**] Sex: MService:DISCHARGE DIAGNOSIS: Right temporal and
putaminal hemorrhage
DISEASE
secondary to amyloid angiopathy.CHIEF COMPLAINT: Left-sided weakness for 2Admission Date: [**2132-4-10**] Discharge Date: [**2132-4-12**]Date of Birth: [**2062-5-2**] Sex: MService: [**Year (4 digits) 662**]
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 663**]Chief Complaint:GI BleedMajor Surgical or Invasive Procedure:EsophagogastroduodenoscopyHistory of Present Illness:69 yo man with
dementia
DISEASE
(AAO x 1 and communicative at baseline)hx
stroke
DISEASE
with dense L
hemiplegia
DISEASE
hx of
GIB
DISEASE
[**2121**] secondary to
duodenal ulcer
DISEASE
who was BIBA for unresponsiveness. Per hiswife his caretaker moved him to his wheelchair. Around 9am helost consciousness and was noted to be diaphoretic and morerigid. He was moved to his bed where he remained unresponsivewith
coffee ground emesis
DISEASE
in his mouth. EMS was called and ptregained consciousness in the ambulance.In the ED initial VS were: T 97.1 P 84 BP 126/90 RR 18O2sat 95
RA
DISEASE
. NG lavage was grossly positive with bright redblood clots and coffee grounds. Pt was guaiac negative. Hct44 Plt 214 INR 1. Two 18 gauge PIVs placed for access andpatient typed & crossed for 2 unitsAdmission Date: [**2173-6-30**] Discharge Date: [**2173-7-15**]Date of Birth: [**2095-6-20**] Sex: MService: SURGERY
Allergies
DISEASE
:CozaarAttending:[**First Name3 (LF) 668**]Chief Complaint:
nausea vomiting
DISEASE
Major Surgical or Invasive Procedure:[**2173-6-30**] ex lap reduction of volvulus enterotomy repair[**2173-7-13**] AVG thrombectomyHistory of Present Illness:78 M presents with 24 hours of
nausea
DISEASE
multiple bouts of
emesis
DISEASE
and
abdominal pain
DISEASE
. Has thrown up non-stop overnight.Reports not passing gas today but has had loose stool. Denies
fevers chills
DISEASE
or any urinary sypmtoms.Past Medical History:- DM-
HTN
DISEASE
-
Dyslipidemia
DISEASE
- Laser surgery to both eyes- Bilateral
cataracts
DISEASE
-
ESRD
DISEASE
on dialysis MWF- Atrial flutter/atrial
fibrillation
DISEASE
s/p ablation. He isreportedly not on anticoagulation because of
renal insufficiency
DISEASE
and concern for high risk of
bleeding
DISEASE
.- s/p pacemaker placement with history of
tachy-brady
DISEASE
syndrome-
Prostate cancer
DISEASE
diagnosed 12 years ago s/p orchietctomy andhormone therapy- Renal cell cancer s/p right nephrectomy- Secondary hyperparathyroidism- Small bilateral
pleural effusions
DISEASE
noted on [**2172-1-17**]admission no longer noted on recent chest x-ray from [**2172-9-24**]- Percutaneous thrombectomy of his left forearm AV graftfistulogramarteriogram and a balloon angioplasty of multiple venousoutflowstenoses and angioplasty of the arteriovenous graft anastomosisin [**2172-6-16**]-s/p surgical removal of upper GI obstruction per patientSocial History:Retired foundry worker who lives at home in [**Location (un) 669**] with hiswife. Stopped smoking cigarettes over 20 years ago smokedintermittently for years before that but has difficultyquantifying use. Has not had alcohol in over 20 years drinkingonly socially prior to that time. Denies a history of drug use.Family History:Family History:States that his siblings are healthy but unsure on health ofother family membersPhysical Exam:97.6 99/48 78 18 100%
RA
DISEASE
Awake alert oriented x 3 NADNG tube in placePERRL anictericRRRCTABAbdomen soft distended tender along midline incision and leftside of the
abdomen hypoactive bowel sounds
DISEASE
Admission Date: [**2173-7-24**] Discharge Date: [**2173-7-28**]Date of Birth: [**2095-6-20**] Sex: MService: MEDICINE
Allergies
DISEASE
:CozaarAttending:[**First Name3 (LF) 678**]Chief Complaint:bright red blood per rectumMajor Surgical or Invasive Procedure:noneHistory of Present Illness:78 year old male with a past medical history significant for DM
HTN atrial fibrillation
DISEASE
on coumadin hx tachy-brady s/ppacemaker
ESRD
DISEASE
on
HD
DISEASE
s/p recent ex-lap *2 for
small bowel
obstruction
DISEASE
night prior to admission BRBPR with INR 2.7 HCT 28at rehab.In the ED T 98.3 HR 64 BP 96/44 RR 16 O2 sat: 100%. Two large
bloody bowel movements
DISEASE
1 hour apart for which patient recieved 2units packed rbc 2 unit FFP vit K 10 mg IV Factor 9. Patientis negative NG lavage then NG tube was removed. Patient seen bysurgery who felt likely due to
diverticular bleed
DISEASE
. GI is awareand will evaluate once in the unit. Patient came in with triplelumen and an 18 gauge was placed. EKG with ST depressionslateral leads with elevated troponin. Cardiology reviewed EKGand did not feel acute cardiac issue. Most recent vitals T 97.2P 60 BP 150/42 R 14 O2 sat 100% on 2LNC.Upon arrival to the intensive care unit. Patient reports nofurther episodes of BRBPR. Patient endorses tender abdomen withany touch but painless at rest. Patient is very hungry butreports he has been eating only small amounts at rehab. Patientreports
cough
DISEASE
productive of brown/red sputum since NG tubeplacement for SBO. Patient was lightheaded this AM but thatresolved with the transfusions.Review of systems:(Admission Date: [**2173-8-27**] Discharge Date: [**2173-9-10**]Date of Birth: [**2095-6-20**] Sex: MService: MEDICINE
Allergies
DISEASE
:CozaarAttending:[**First Name3 (LF) 678**]Chief Complaint:78 yo male with
ESRD
DISEASE
came in with
abdominal pain
DISEASE
Major Surgical or Invasive Procedure:Ultrasound-guided percutaneous cholecystostomy withno immediate complications. 8-French catheter was left in situin satisfactory position.PICC line placementPercutaneous cholecystostomy tube removal by patientHistory of Present Illness:78 year old male who is status post exploratory laparotomylysis of
adhesions
DISEASE
and
reduction of small bowel volvulus
DISEASE
in[**6-/2173**] by Dr [**First Name (STitle) **] was admitted withdiffuse
abdominal pain
DISEASE
for one month. He had a CT scan and RUQUS that showed cholilithiasis thickened wall and [**Doctor Last Name 515**] sign.Past Medical History:- DM-
HTN
DISEASE
-
Dyslipidemia
DISEASE
- Laser surgery to both eyes- Bilateral
cataracts
DISEASE
-
ESRD
DISEASE
on dialysis MWF- Atrial flutter/atrial
fibrillation
DISEASE
s/p ablation. He isreportedly not on anticoagulation because of
renal insufficiency
DISEASE
and concern for high risk of
bleeding
DISEASE
.- s/p pacemaker placement with history of
tachy-brady
DISEASE
syndrome-
Prostate cancer
DISEASE
diagnosed 12 years ago s/p orchietctomy andhormone therapy- Renal cell cancer s/p right nephrectomy- Secondary hyperparathyroidism- Small bilateral
pleural effusions
DISEASE
noted on [**2172-1-17**]admission no longer noted on recent chest x-ray from [**2172-9-24**]- Percutaneous thrombectomy of his left forearm AV graftfistulogramarteriogram and a balloon angioplasty of multiple venousoutflowstenoses and angioplasty of the arteriovenous graft anastomosisin [**2172-6-16**]-s/p surgical removal of upper GI obstruction per patientSocial History:Retired foundry worker who lives at home in [**Location (un) 669**] with hiswife. Stopped smoking cigarettes over 20 years ago smokedintermittently for years before that but has difficultyquantifying use. Has not had alcohol in over 20 years drinkingonly socially prior to that time. Denies a history of drug use.Family History:Family History:States that his siblings are healthy but unsure on health ofother family membersPhysical Exam:Exam at admission:Vital Signs: T 97.4 HR 86 BP 104/42 RR 18 O2 Sat 100General: No acute distressCardiovascular: Regular rate and rhythmRespiratory: Clear to auscultation bilaterallyAbdomen: midline incision well healed. No
erythema
DISEASE
. Softdiffusely tender nondistended no tap tenderness.Pertinent Results:Labs on Admission:[**2173-8-27**] 08:05PM WBC-9.2 RBC-3.63* HGB-10.3* HCT-33.4* MCV-92MCH-28.2 MCHC-30.8* RDW-15.9*[**2173-8-27**] 08:05PM ALT(SGPT)-62* AST(SGOT)-43* ALK PHOS-87 TOTBILI-0.6[**2173-8-27**] 08:05PM PT-14.8* PTT-37.6* INR(PT)-1.3*[**2173-8-27**] 08:22PM LACTATE-2.0 KAdmission Date: [**2160-4-10**] Discharge Date: [**2160-4-17**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 689**]Chief Complaint:
Rectal bleeding
DISEASE
Major Surgical or Invasive Procedure:ColonoscopyEsophagogastroduodenoscopyHistory of Present Illness:87 yo F with h/o CAD A fib on coumadin HTN hyperchol
hypothyroidism
DISEASE
p/w
melena
DISEASE
. Pt notes that for the past 2.5 weeksshe has been Admission Date: [**2119-6-7**] Discharge Date: [**2119-7-18**]Date of Birth: [**2063-7-15**] Sex: FService: SURGERY
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 695**]Chief Complaint:UnresponsiveMajor Surgical or Invasive Procedure:evacuation of
abdominal wall hematoma
DISEASE
and paracentesisre-exploration of
abdominal wall hematoma
DISEASE
with surgicel packingHistory of Present Illness:55yoF with
alcoholic cirrhosis s/p TIPS [**1-/2118**]
DISEASE
found down by herhusband.The patient has a history of
depression
DISEASE
which her husband [**Name (NI) **]reports has been exacerbated lately by several stressfulsituations including her
chronic back pain
DISEASE
finances etc. Shewas last seen to be interactive and appropriate at 06:00am thismorning by her husband. [**Name (NI) **] son saw her at 11am but thoughtthe patient was asleep and did not attempt to wake her. She wassubsequently found down on the floor by her husband at 3pm 9hours after last being seen who describes her as being in afetal position with her eyes rolled to the back of her head andher mouth wide open. Her husband began to lift the patient offthe floor and she bit him on the shoulder and did not appear torecognize him. She was take to [**Hospital6 33**] where shewas was found to be responsive to verbal stimuli but unable tointeract appropriately. She was intubated. Coffee groundsreturned from her OGT and she was
hypotensive
DISEASE
in the 80's/40's.FS was 22 and received glucose T was 94.6 and she was placedon a bear hugger. pH was 6.8 lacate 25 creatine 3.2 bicarb4. She was received 2 amps bicarb 1 amp D50 and bloodcultures were drawn from her central line. She was started onbicarb drip levophed gtt for SBP 80's. She not making urineafter 6L IVF. She was transferred to [**Hospital1 18**] for furthermanagement. R IJ was placed at the OSH and 2 peripheral IVs..Per the husband's report the patient does have a history ofsurreptitious alcohol ingestion on occasion but he has notnoticed or detected any alcohol use recently. He denies thelikelihood of illicit drug use or prescription drug
overdose
DISEASE
stating the only medication she has access to is Tramadol whichshe had not been taking. He denies recent vocalizations by thepatient regarding
suicidal ideation
DISEASE
..In the [**Hospital1 18**] ED initial VS: 123 113/29 27 100%The patient was noted to have 150cc dark coffee ground outputfrom her OGT but stool was guiac negative. Hepatology wasconsulted and the patient was started on an Octreotide gtt andPantoprazole gtt and
aggressive flushing
DISEASE
of the OGT wasrecommended. She was ordered to be transfused 1 unit PRBC. Shewas empirically treated with Vanc/Levo/Flagyl and CT torso wasobtained which showed no evidence of
infection
DISEASE
or
acute bleed
DISEASE
.She received 8L IVF in the ED and was increased on Levophed0.4mcg/kg/hr. Renal was consulted as the patient had a poor UOPand was acidotic and CVVH vs hemodialysis was discussed. Thepatient was given Calcium gluconate 2gm Bicarb gtt Admission Date: [**2108-5-9**] Discharge Date: [**2108-5-17**]Date of Birth: [**2023-10-18**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 710**]Chief Complaint:
Fever cough
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:Mr. [**Known lastname 711**] is an 84 M with h/o MI CABG
CHF
DISEASE
presents with 4days of worsening mildly productive
cough
DISEASE
. On the night beforeadmission his
cough
DISEASE
worsened and he felt warm with a
fever
DISEASE
to101. He tried his wife's albuterol which did not help. He deniesSOB sore
throat congestion chest pain lightheadedness
DISEASE
headache
DISEASE
dysuria/frequency
abdominal pain
DISEASE
diarrhea/constipation. Over the past month he has reduced hissalt intake and lost 25 lbs after being in congestive heartfailure. He no longer has any lower extremity edema. He recentlyhad
shingles
DISEASE
over his right eye..In the ED initial VS were: 100 94 117/46 18 95/ 2LNC. Exambilateral rales RAdmission Date: [**2199-2-8**] Discharge Date: [**2199-2-14**]Date of Birth: [**2161-11-27**] Sex: MService: TRAUMA SURGERYHISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 2212**] is a 37-year-oldmale who was stabbed by a four inch knife to the left upperabdomen. In the field his blood pressure was 120/palpableheart rate 120. A pressure dressing was applied to thewound. Reportedly the knife penetrated about 1.5 inches.PAST MEDICAL HISTORY:1. HIV positive for 21 years.2. History of intravenous
drug abuse
DISEASE
.3.
Hypertension
DISEASE
.4. Congestive
heart failure
DISEASE
.5. Right above the knee amputation after being hit by atruck in the past.6. Tricuspid regurgitation.ADMISSION MEDICATIONS:1. Epivir.2. Ziagen.3. Bactrim Double Strength.4. Lasix.5. Methadone.6. Lopressor.7. Prilosec.8. Risperdal.9. Aldactone.10. Folate.11. Multivitamins.12. Thiamine.ALLERGIES: The patient has an
allergy
DISEASE
to penicillin.PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature97.3 heart rate 116 blood pressure 140/palpablerespiratory rate 16 pulse oximetry of 100%. General: Hewas alert and oriented times three with a
GCS
DISEASE
of 15. HEENT:Normocephalic atraumatic. Extraocular motions were intact.The pupils were equal round and reactive to light andaccommodation. The oropharynx was clear. The TMs wereclear. Chest: Clear to auscultation bilaterally with nosubcutaneous air noted. Cardiac: No murmurs rubs orgallops. Regular rate and rhythm. Abdomen: There was a 1.5cm left upper quadrant wound otherwise diffusely tender.Back: No
step-off
DISEASE
. No
deformities
DISEASE
. Nontender.Extremities: A right above the knee amputation withprosthesis. Left leg with chronic venostasis changes.Rectal: Good tone. Contaminated by external blood.Neurological: No
focal deficits
DISEASE
.LABORATORY DATA UPON ADMISSION: Chemistries generally normalwith creatinine of 1.2. Blood gas 7.39/49/341/31/4 lactate2.5 amylase 107 fibrinogen 171. PT 15.8 PTT 36.1 INR1.7. His white blood count was 5.1 hematocrit 34.4. Urinetoxicology was not performed.A chest x-ray was within normal limits status post leftsubclavian line placement which was in place.HOSPITAL COURSE: The patient was taken to the Operating Roomfor wound exploration directly from the
Trauma
DISEASE
Room. Thepatient was taken to the Operating Room as mentioned abovefor an exploratory laparotomy extensive lysis of adhesionsand control of rectus and omental
bleeding
DISEASE
. The estimated
blood loss
DISEASE
was approximately 1000 cc. Please see theoperative note dictated by Dr. [**Last Name (STitle) **] on [**2199-2-8**] forcomplete report.The patient was then transferred to the SICU where his
coagulopathy
DISEASE
was corrected. He received 4 units of packedred cells 4 units of FFP and 1 cryoprecipitate.While on the unit he was extubated on [**2199-2-10**] SICUday number three and he was noted to have progressive
thrombocytopenia
DISEASE
. His home p.o. medications were restartedas well.On [**2199-2-11**] hospital day number four the patientwas transferred to the floor. His diet was advanced and hewas placed on an
aggressive bowel
DISEASE
regimen to get his bowelsmoving postsurgically. The
Pain
DISEASE
Service was also consultedbecause of the patient's history of narcotic abuse and hiscontinued complaints of
pain
DISEASE
. They recommended increasinghis dose of Klonopin and starting MSIR.On hospital day number five the patient was noted to have a
heparin-induced
DISEASE
antibody which may be one of the reasons hewas
coagulopathic
DISEASE
on admission although his
HIV disease
DISEASE
andother
drug abuse
DISEASE
cannot be ruled out as cause. His plateletcount remained relatively stable however as did hishematocrit.By hospital day number six the patient was doing somewhatbetterAdmission Date: [**2157-3-21**] Discharge Date: [**2157-3-27**]Date of Birth: [**2093-2-22**] Sex: FService:HISTORY OF PRESENT ILLNESS: 64-year-old woman with historyof right parietal occipital hemorrhage in [**10/2156**] with anadmission to the Neurology service. She presented with
headaches
DISEASE
and
unsteadiness
DISEASE
the last two weeks. Headaches areunclear duration. Very forgetful since [**54**]/[**2156**]. She hasbeen slowing down as per her family. Being forgetfulpositive
chills
DISEASE
no
fevers
DISEASE
positive
nausea
DISEASE
no
vomiting
DISEASE
positive
diarrhea
DISEASE
over last two to three days
cough
DISEASE
positivelast three days.PAST MEDICAL HISTORY:1.
Hypertension
DISEASE
.2. Anxiety.3. Hepatitis C.4.
Right parietal-occipital hemorrhage
DISEASE
in 09/[**2156**].5. Normal stress test in 11/[**2156**].MEDICATIONS:1. Keppra.2. Metoprolol.3. Epogen.ALLERGIES:1. Penicillin.2. Codeine.SOCIAL HISTORY: Lives aloneAdmission Date: [**2157-3-20**] Discharge Date: [**2157-3-30**]Date of Birth: [**2093-2-22**] Sex: FService: NEUROSURGERYHISTORY OF PRESENT ILLNESS: The patient is a 64-year-oldwoman with a history of right parietal occipital hemorrhagein [**2156-10-4**]. She was admitted at that time to theNeurology Service.She presented with
headaches
DISEASE
and
unsteadiness
DISEASE
for the lasttwo weeks. Headaches were of unclear duration as she hasbecome very forgetful since [**2156-2-4**].She has been getting lost in the grocery store has had no
fever
DISEASE
positive
nausea
DISEASE
no
vomiting
DISEASE
positive
diarrhea
DISEASE
forthe last 2-3 days. She has had positive
chest pain
DISEASE
on andoff but none over the last two days prior to admission. No
cough
DISEASE
over the last two days prior to admission.PHYSICAL EXAMINATION: Vital signs: Temperature 97.8Admission Date: [**2199-3-18**] Discharge Date: [**2199-3-25**]Date of Birth: [**2139-8-15**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 759**]Chief Complaint:
Hypertensive
DISEASE
urgencyMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:This is a 59 yo F with a history of
DM2
DISEASE
and
HTN
DISEASE
who presentswith L greater than R flank
pain
DISEASE
associated with
nausea
DISEASE
and
visual blurring
DISEASE
. Patient has had L sided flank
pain
DISEASE
since thenight prior to admission. This was associated with blurry visionfor the past 1-2 days and
headache
DISEASE
over the last few hours. Shehas not had
dysuria hematuria vomiting
DISEASE
or
fevers
DISEASE
. No
abdominal pain
DISEASE
. No
diarrhea
DISEASE
.She does have a history of
HTN
DISEASE
and is compliant with herantihypertensives.Of note she had much more severe
flank pain
DISEASE
6 weeks ago. Shewas told to drink fluids for potential
kidney stone
DISEASE
. She hadimaging done in [**State 760**] at her home that showed no obviousstones. Apparently she was referred to a nephrologist at thattime and was told she had some evidence of
kidney failure
DISEASE
. Shewas first told she may have
kidney failure
DISEASE
in [**2198-4-22**]. She wasseen by nephrology but does not know any further details. Shehas never been on dialysis before. She did not have this flank
pain
DISEASE
at that time.Patient brought labs from previous appointments.[**1-16**] Cr 3.29.[**2-4**] Cr 3.07 HCT 31.1.In the emergency department BP was 221/71. She recived 200mg IVlabetalol and was started on a 1mg/min labetalol gtt. BP camedown to 176/92. HR 77. RR21. O2 sat 88%.On arrival to the MICU patient's flank
pain
DISEASE
is much improved.No
headache nausea vomiting chest pain
DISEASE
or shortness ofbreath.Past Medical History:1.
Diabetes
DISEASE
2. Asthma3.
Depression
DISEASE
4. History of pulmonary nodules consistent with calcified
granuloma
DISEASE
5.
Menorrhagia
DISEASE
6.
Hypertension
DISEASE
7.
Hypercholesterolemia
DISEASE
.8. Chronic lower back
pain
DISEASE
.9. CRI most recent Cr values in the low 3's.10. Thyroid mass - she reports she was told she had a 2 cm
thyroid mass
DISEASE
and needed to have this biopsied.11.
Osteoporosis
DISEASE
Social History:She lives in NJ currently with a roommate but wants to moveback to MA. Smokes 1 ppd. Denies alcohol or drug use.Family History:Uncle and two cousins had
kidney disease
DISEASE
requiring dialysis.Physical Exam:Vitals - T: BP: HR: RR: 02 sat:GENERAL: Pleasant well appearing female sitting on the bed inNADHEENT: Normocephalic atraumatic. No
conjunctival pallor
DISEASE
. No
scleral icterus
DISEASE
. PERRLA/EOMI. MMM. OP clear.NECK: Full thyroid bilaterally with a focal small nodule on theleft lobe.CARDIAC: Regular rhythm normal rate. Normal S1 S2. No murmursrubs or [**Last Name (un) 549**].LUNGS: Patient breathing comfortably. CTAB good air movementbiaterally.ABDOMEN: Admission Date: [**2200-4-25**] Discharge Date: [**2200-4-28**]Date of Birth: [**2139-8-15**] Sex: FService: [**Year (4 digits) **]
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 824**]Chief Complaint:R renal massMajor Surgical or Invasive Procedure:Right Laparoscopic Radical NephrectomyHistory of Present Illness:60yF with CAD and
ESRD
DISEASE
on
HD
DISEASE
with a nearly 4cm left renal massconcerning for
malignancy
DISEASE
.Past Medical History:1.
Diabetes type 2 c/b retinopathy neuropathy
DISEASE
- pt notcurrently taking meds due to insurance issue2. Reactive airway diseaseAdmission Date: [**2200-10-21**] Discharge Date: [**2200-10-27**]Date of Birth: [**2139-8-15**] Sex: FService: MEDICINE
Allergies
DISEASE
:Iron Dextran ComplexAttending:[**First Name3 (LF) 832**]Chief Complaint:
respiratory failure
DISEASE
Major Surgical or Invasive Procedure:BronchoscopyIntubationHemodialysis after HD line placementHistory of Present Illness:61 year-old female with
ESRD
DISEASE
on
HD
DISEASE
Stage IV
NSLC lung cancer
DISEASE
(EGFR wild type) DM2
HTN
DISEASE
who presents with respiratorydistress.Patient was with
cough
DISEASE
and not feeling well this AM. She went todialysis where she was coughing intensely to the point that theneedles came out of her AV graft. She appeared short of breath.Unclear what EMS course was. Upon presentation to the ED hereyes were open but she was none verbal. Some history obtained bycousin in [**Name (NI) **].Of note her
lung cancer
DISEASE
involves the right upper lobe mass andadjacent hilar/mediastinal/supraclavicular nodes. Patient metwith Dr. [**Last Name (STitle) **] in [**Month (only) **] who started vinorelbin forpalliative chemotherapy about 2 weeks ago.In addition patient's admit weight was 62 kg with an estimateddry weight of 58 kg.ED Course:Initial VS at 11:40 on [**10-21**] were T 97.7 HR 100 BP 181/69 RR 32Sat 84 %. She triggered for
respiratory distress
DISEASE
. Eyes were openbut non-verbal. There was a question about intubation/codestatus. ED physician spoke to next of [**Doctor First Name **] (Mr.[**Last Name (Titles) 732**]). He statedthat she would want to be intubated. Intubated with 7.5 ETT withricironium 60 mg and etomidate 20 mg. Sedation with versed andpropofol. After intubation VS were 95 125/59 25 99% on ventCXR revealed RUL opacity. She was given ceftriaxone 1 gm IV x 1and levofloxacin 750 mg IV x 1 initially followed by addition ofvancomycin 1 gm IV x 1 to cover
HCAP
DISEASE
. EKG showing Sinus TachTWI V4-6 Admission Date: [**2143-8-23**] Discharge Date: [**2143-8-27**]Date of Birth: [**2077-7-13**] Sex: MService: CCUHISTORY OF PRESENT ILLNESS: This is a 66-year-old man withsevere CAD status post CABG in [**2135**] with recent PCI to theLMCA and SVG to the PDL in [**2143-7-14**]. He presented on[**2143-8-23**] for an elective intervention brachytherapy of theSVG to PL and native RCA. The patient reported that he hadbeen feeling well without
chest pain shortness of breath
DISEASE
or
dyspnea
DISEASE
on exertion. He was noted to have an ejectionfraction of greater than 60 percent in [**2143-7-14**]. Thepatient underwent a cardiac catheterization on the morning ofarrival with PCI to the native RCA and 4 stents andbrachytherapy to the vein graft. The patient tolerated theprocedure well and approximately 6 hours later developed a
chest pain
DISEASE
noted as 4 out of 10 substernal radiating to histhroat and back without
shortness of breath diaphoresis
DISEASE
nausea
DISEASE
or
vomiting
DISEASE
. EKG at that time revealed ST elevationin II III and aVF. The patient was brought back to thecatheterization laboratory at that time. They found that theSVG to PL have been
thrombosed
DISEASE
. The artery was opened in thecatheterization laboratory AngioJet had been unsuccessfuland the graft was opened with Nipride with subsequent TIMI 3flow. The patient had persistently occluded communicationbetween the native RCA and the vein graft. Postprocedureafter the sheath pull a
hematoma
DISEASE
developed and the patienthad baseline low blood pressure of systolic in the 90s.PAST MEDICAL HISTORY:1. Status post MI in [**2129**].2. PCI to the LAD in [**2130**].3. PCI to the RCA in [**2132**] complicated by a stent blocking the femoral artery.4. Status post iliac repair.5. Coronary artery bypass graft in [**2135**] including LIMA to the LAD SVG to the D1 SVG to the
RPL
DISEASE
.6. PCI to the LMCA in [**2143-7-14**] PCI to the SVG to the PVL.7. Status post right knee arthroscopy.8. History of
hemorrhoids
DISEASE
.9. History of benign polyps.MEDICATIONS ON PRESENTATION:1. Aspirin 325 mg a day.2. Lopressor 12.5 mg b.i.d.3. Zocor 60 mg a day.4. Plavix 75 mg a day.ALLERGIES: No known drug
allergies
DISEASE
.SOCIAL HISTORY: Smokes 10 packs a week for the past 50years currently trying to quit. Social tobacco with noillicits.FAMILY HISTORY: A brother died of MI at age 60. Father hadhis first MI in his 50s. The patient is married with severalchildren. He is currently between jobs. After theprocedure the patient was admitted to the CCU formonitoring.PHYSICAL EXAMINATION: His temperature was 98.2 degreesblood pressure 99/48 respiratory rate 15 100 percentsaturation on room air heart rate 57 to 66. In general heis a well-appearing elderly male alert and oriented with anappropriate affect. HEENT revealed no JVD. Supple neck.Chest revealed clear lungs no rhonchi no crackles.Cardiovascular normal S1 S2 no murmurs rubs or gallopsno S3 or S4. Abdomen is flat soft nontender nondistendedwith
normoactive bowel sounds
DISEASE
. Extremities are warm withcapillary refill less than 3 seconds 2 plus DP and PT andradial pulses no
edema left groin
DISEASE
with bruit.LABORATORY DATA: EKG on presentation had a sinus rate of 55
inferior T-wave
DISEASE
inversions ST elevation in V1 and V2.IMPRESSION: The patient is a 66-year-old male with a severeCAD status post brachytherapy SVG to the PDL withsubsequent
thrombosis
DISEASE
status post opening of the arteryduring repeat catheterization.HOSPITAL COURSE: The patient was now hemodynamically stablewith resolution of his EKG changes and ST elevation and hewas admitted to the CCU for monitoring. That evening thepatient complained of back
pain
DISEASE
on his left side which heattributed to lying on his back. On exam there was nopalpable
hematoma
DISEASE
no bruit auscultated and strong DP pulseswith warm extremities. The CT of the pelvis and abdomen wasnegative for
retroperitoneal bleed
DISEASE
. It was determined thatthe patient's
pain
DISEASE
was due to back painAdmission Date: [**2188-8-14**] Discharge Date: [**2188-8-23**]Service: General Surgery - Blue TeamHISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year oldyoung lady with a history of
hypothyroid
DISEASE
previousappendectomy and hysterectomy who presented to the EmergencyDepartment with a one day history of severe
abdominal pain
DISEASE
.The patient endorses
nausea
DISEASE
without
vomiting sweating
DISEASE
dysuria
DISEASE
chest pain
DISEASE
and
shortness of breath
DISEASE
. The patientdid not have any prior episodes of this type of
pain
DISEASE
. Thepatient has no history of
ulcers
DISEASE
. The patient's last bowelmovement was [**8-14**] it was normal. The patienttolerated breakfast by mouth today without any complications.PHYSICAL EXAMINATION: On physical examination the patientwas afebrile 100.0 heartrate 80 blood pressure 148/74respiratory 24 99% on room air. In general she was alertand oriented times three. Cardiac examination was irregular.Chest examination with a fair amount of air entry. Abdominalexamination
tenderness guarding
DISEASE
mainly in the right lowerquadrant. Positive tympani. Extremities were warm no
edema
DISEASE
or
erythema
DISEASE
. Rectal examination guaiac negative.LABORATORY DATA: Laboratory data on admission revealed whitecount 13.7 hematocrit 42 platelets 397 sodium 139potassium 4.1 chloride 97 bicarbonate 34 BUN 19creatinine 1.0 glucose 127. Liver function tests ALT 16AST 28 alkaline phosphatase 78 total bilirubin 0.5 amylase43. Urinalysis trace leukocytes small blood traceketones red blood cells [**2-13**] and white blood cells [**2-13**].Chest x-ray showed free air in his diaphragm on the right.Abdominal x-rays upright film showed free air with air inthe colon. Stool absent all the way down through the colon.HOSPITAL COURSE: The patient was admitted and placed onAmpicillin Levofloxacin and Flagyl. Blood cultures weresent. On hospital day #1 [**2188-8-15**] the patientunderwent partial gastrectomy and gastrojejunostomy withplacement of feeding J-tube for a perforated
gastric ulcer
DISEASE
.The patient tolerated the procedure well and there were nocomplications during the surgery. The patient was placed inthe Intensive Care Unit over night intubated. On [**2188-8-16**] postoperative day #1 the patient was weaned fromventilator support and extubated without difficulty. Thepatient's renal function improved to producing over 30 cc/hrand soft bowel sounds were appreciated. On postoperative day#3 the patient was transferred to the floor. On the floorthe patient was started on half-strength tube feeds. Totalparenteral nutrition was continued and by [**8-21**]postoperative day #6 the patient was tolerating sips. On theday of [**8-20**] the patient had one episode of atrial
fibrillation
DISEASE
that was successfully controlled withintravenous Lopressor. By [**8-22**] the patient wastolerating liquids without difficulty. Total parenteralnutrition had been stopped antibiotics had been stopped andrehabilitation planning had started. Tube feeds wereincreased to almost goal. On [**8-23**] the patient wastolerating full liquids without difficulty and was dischargedto rehabilitation. The patient will be discharged to[**Hospital **] Rehabilitation in good condition. She is able toambulate with assistance tolerate full liquids and has nofurther need for antibiotics.DISCHARGE DIAGNOSIS:1. Status post partial gastrectomy for
perforation
DISEASE
of gastric
ulcer sepsis
DISEASE
2. Status post gastrojejunostomy3. Status post placement offeeding J-tube4. Hypothyroid5. Status post appendectomy6. Status post hysterectomy7. Coronary Artery Disease
Hypertension
DISEASE
8.
Dementia
DISEASE
9.
Malnutrition
DISEASE
10.
Esophageal Motility Disorder
DISEASE
DISCHARGE MEDICATIONS:1. Acetaminophen 325 mg tablets one to two tablets by mouthq. 4-6 hours as needed2. Metoprolol 50 mg tablets [**12-15**] tablet by mouth twice a day3. Pantoprazole 40 mg tablets one tablet every 24 hours4. Prednisone 10 mg one tablet by mouth three times a day [**Name6 (MD) 843**] [**Name8 (MD) 844**] M.D. [**MD Number(1) 845**]Dictated By:[**Name8 (MD) 846**]MEDQUIST36D: [**2188-8-23**] 09:54T: [**2188-8-23**] 11:26JOB#: [**Job Number 847**]Admission Date: [**2164-6-15**] Discharge Date: [**2164-7-13**]Date of Birth: [**2115-11-19**] Sex: MService: NEUROLOGY
Allergies
DISEASE
:Phenobarbital / Depakote / Zarontin / Gabapentin / Zonegran /Tranxene SdAttending:[**First Name3 (LF) 848**]Chief Complaint:
Emesis lethargy
DISEASE
and decreased PO intakeMajor Surgical or Invasive Procedure:Central Venous Line placement
Small bowel exploratory
DISEASE
laparotomySmall-bowel resection with primary anastomosisHistory of Present Illness:A 48-year-old patient who presents episodically for evaluationof
emesis
DISEASE
. Pt has a complicated PMH including [**Location (un) 849**]
Gastaut
DISEASE
Syndrome mental retardation
DISEASE
and
seizure disorder
DISEASE
He wasrecently admitted to [**Hospital1 18**] from [**2164-5-4**] to [**2164-5-18**] andthen subsequently to [**Hospital **] Rehabilitation status post exlapopen chole J-tube placement and venting decompressedcolotomy for
abdominal pain
DISEASE
. Pt was brought back to [**Hospital1 18**] byhis caregivers because of
emesis lethargy
DISEASE
and decreased POintake. It was unclear if the
emesis
DISEASE
was
bilious
DISEASE
or bloody.
Denies
DISEASE
any change of
bowel movements
DISEASE
. No
fevers
DISEASE
recorded atliving center. No other focal complaints. The patient has beenunable to provide any history. Per caregivers the patient doesnot report
pain
DISEASE
although at baseline it is unclear if heexperiences
pain
DISEASE
.Past Medical History:[**Location (un) 849**] Gastaut Syndrome [**Location (un) 850**] Dr. [**Last Name (STitle) 851**]
Seizure disorder
DISEASE
Mental retardation
Osteoporosis
DISEASE
Peripheral neuropathy
DISEASE
secondary to dilantinh/o
hyponatremia
DISEASE
secondary to trileptalGERDBehavioral d/os/p recent ex lap open cholecystectomy J-tube placement andtransverse colon needle decompressionSocial History:Lives in group home. Non-verbal at baseline. Does not smoke ordrink EtOH.Patient lives in a group home. # [**Telephone/Fax (1) 852**]. Has a legalguardian Rev [**First Name8 (NamePattern2) **] [**Name (NI) 853**] c # [**Telephone/Fax (1) 854**] w # [**Telephone/Fax (1) 855**].Family History:NoncontributoryPhysical Exam:PHYSICAL EXAMINATION:VITAL SIGNS: Blood pressure 120/60 temperature 97.7 heartrate 98.GENERAL: Gentleman appears chronically ill in a wheelchairnontoxic.HEENT: Oropharynx notable for somewhat dry membranes. He isanicteric.LUNG: Complicated by poor effort but no crackles areappreciated.CARDIAC: Notable for mild
tachycardia
DISEASE
.ABDOMEN: Soft. J-tube site appears somewhat erythematous.There is no discharge. There are bowel sounds. No palpable
organomegaly
DISEASE
.Neuro Exam very limited since pt is non-verbal at baseline andunable to cooperate with exam:MSE: Awake and alertAdmission Date: [**2164-11-23**] Discharge Date: [**2164-12-4**]Date of Birth: [**2115-11-19**] Sex: MService: MEDICINE
Allergies
DISEASE
:Phenobarbital / Depakote / Zarontin / Gabapentin / Zonegran /Tranxene SdAttending:[**First Name3 (LF) 678**]Chief Complaint:[**First Name3 (LF) **]Major Surgical or Invasive Procedure:NoneHistory of Present Illness:49 year-old man with a history of presumed [**Location (un) 849**]
Gastaut
DISEASE
Syndrome
DISEASE
and with a recent complicated medical history presentsthis morning for a [**Location (un) 862**] in the setting of
fever
DISEASE
. The patientis nonverbal and the history was obtained through medical record.The patient was reportedly well yesterday and was stable whenlast checked at 11 pm. He was noted to be Admission Date: [**2166-12-9**] Discharge Date: [**2166-12-21**]Date of Birth: [**2115-11-19**] Sex: MService: MEDICINE
Allergies
DISEASE
:Phenobarbital / Depakote / Zarontin / Gabapentin / Zonegran /Tranxene-SDAttending:[**First Name3 (LF) 678**]Chief Complaint:
fever
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:51 yo male with h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 849**]-Gastaut with
MR
DISEASE
presenting from grouphome after one day of
fever
DISEASE
. History provided by worker fromgroup home. Noted to develop temperature of 99.6 -Admission Date: [**2203-11-3**] Discharge Date: [**2203-11-12**]Date of Birth: [**2161-11-27**] Sex: MService: MEDICINE
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 348**]Chief Complaint:
Shortness of breath chest pain
DISEASE
Major Surgical or Invasive Procedure:PericardiocentesisEGD with biopsyHistory of Present Illness:41 y/o M w/ h/o HIV/AIDS (HIV dx 83
AIDS
DISEASE
92 last CD4 132 VLAdmission Date: [**2192-5-16**] Discharge Date: [**2192-5-29**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 898**]Chief Complaint:
bloody diarrhea
DISEASE
x 2 weeksMajor Surgical or Invasive Procedure:colonoscopy x 2 (Admission Date: [**2192-6-3**] Discharge Date: [**2192-6-10**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 905**]Chief Complaint:Lower
gastrointestinal blees
DISEASE
Major Surgical or Invasive Procedure:1. Colonoscopy2. Tagged
RBC GI bleeding
DISEASE
studyHistory of Present Illness:Pt. is an 83y/o F with a PMH of
diverticulosis
DISEASE
recentlydischarged on [**2192-5-29**] s/p
LGIB
DISEASE
secondary to
bleeding
DISEASE
diveriticulus admitted [**6-3**] with BRBPR..During prior hospitalization pt. was admitted with a 2 weekhistory of BRBPR at home. On [**5-21**] a
diverticular bleed
DISEASE
found onfirst colonoscopy epi injected but patient with continued
LGIB
DISEASE
which was seen in the distal sigmoid on tagged RBC study [**5-24**].The
bleeding
DISEASE
was not deemed amenable to angio intervention.Repeat colonoscopy on [**5-25**] not able to identify further source of
bleeding
DISEASE
. Pt discharged on [**5-29**] with a stable hct..Since that time Pt. was doing well at home until she again hadan episode of BRBPR which she reported to fill the commode. Pt.also reported L
chest pain
DISEASE
occurring episodically over the pastfew days. Pt. brought to ED by her daughter yesterday. In EDvitals: temp 97 HR 110 BP 161/90 RR 18 O2sat 98% 4LNC. Pt.soaked her pad on ED bed with BRB. Labs included HCT 37unremarkable CBC electrolytes CEs and LFTs. CXR unremarkable.EKG SRAdmission Date: [**2102-4-13**] Discharge Date: [**2102-4-17**]Date of Birth: [**2026-1-20**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 922**]Chief Complaint:
chest pain
DISEASE
Major Surgical or Invasive Procedure:[**4-13**] MVR (29mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] porcine)History of Present Illness:76 yo F walking to dentists office [**3-22**] and hadSOB/CP/diaphoresis. Transferred to [**Hospital1 18**] where cath showed 4Admission Date: [**2102-9-27**] Discharge Date: [**2102-9-30**]Date of Birth: [**2026-1-20**] Sex: FService: NEUROSURGERY
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 78**]Chief Complaint:fallMajor Surgical or Invasive Procedure:noneHistory of Present Illness:HPI:76yo female retired nun presents from [**Hospital3 934**]Hospital s/p fall down down [**5-16**] steps. Pt was alert upon emsarrival and became unresponsive enroute to hospital. Pt. CT scanrevealed bilateral SDH left greater than right. Admission Date: [**2179-5-24**] Discharge Date: [**2179-5-31**]Date of Birth: [**2116-7-18**] Sex: FService: MEDICINE
Allergies
DISEASE
:Percocet / Penicillins / Aspirin / Ibuprofen / Codeine / Reglan/ Morphine Sulfate / Dilaudid / Demerol / Darvocet-N 100 /Erythromycin Base / Tetracycline / OxycodoneAttending:[**First Name3 (LF) 759**]Chief Complaint:Back
pain
DISEASE
Major Surgical or Invasive Procedure:Anterior/posterior lumbar fusion with instrumentation L2-S1History of Present Illness:62 year old female with chronic low back
pain
DISEASE
s/p multiplelumbar surgeries presents for elective anterior/posteriordecompression laminectomy on [**2179-5-25**].Past Medical History:h/o
depression
DISEASE
and Admission Date: [**2195-2-5**] Discharge Date: [**2195-5-28**]Date of Birth: [**2120-5-13**] Sex: FService: Cardiothoracic SurgeryCHIEF COMPLAINT:
Shortness of breath chest pain
DISEASE
x 2 weeks.HISTORY OF PRESENT ILLNESS: The patient is a 74-year-oldfemale with increased
shortness of breath and chest pain
DISEASE
withexertion x 2 weeks. She went to an outside hospital and wastransferred here to [**Hospital1 69**] forcatheterization. The patient had right CA stent placed in[**2188**]. Cardiac catheterization showed 90% left anteriordescending
coronary artery stenosis
DISEASE
90% diagonal stenosis90%
circumflex stenosis
DISEASE
and 80% right coronary arterystenosis. Ejection fraction was roughly 68%.PAST MEDICAL HISTORY: 1.
Coronary artery disease
DISEASE
. 2.
Myocardial infarctions
DISEASE
in the past. 3. Insulin dependent
diabetes mellitus
DISEASE
. 4.
Hypertension
DISEASE
. 5. Increasedcholesterol. 6.
Coronary artery disease
DISEASE
status postpercutaneous transluminal coronary angioplasty of rightcoronary artery in [**2188**]. 7.
Skin cancer
DISEASE
. 8.
Sleep apnea
DISEASE
.9. History of
abdominal hernia
DISEASE
. 10.
Uterine cancer
DISEASE
statuspost radiation. 11. History of
vertigo
DISEASE
. 12. History of
osteoarthritis
DISEASE
. 13. History of
obesity
DISEASE
.PAST SURGICAL HISTORY: 1. Status post
skin cancer
DISEASE
excisionof the face. 2. Status post esophageal dilatation. 3.Status post gastric bypass with
hernia
DISEASE
repair. 4. Statuspost total abdominal hysterectomy. 5. Status post right
cataract
DISEASE
eye surgery.MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Meclizine 12.5mg p.o. b.i.d. 3. Lantus 25 units subcutaneous p.m. 4.Zoloft 75 mg p.o. q.d. 5. Regular insulin 6 units atbreakfast 8 units at lunch 10 units at supper. 6.Neurontin 300 mg p.o. t.i.d. 7. Norvasc 10 mg p.o. q.d. 8.Lasix 40 mg p.o. q.d. 9. Lipitor 40 mg p.o. q.d. 10.Zestril 5 mg p.o. q.d. 11. Scopolamine patch.ALLERGIES: The patient has no known drug
allergies
DISEASE
.PHYSICAL EXAMINATION: On initial examination the patient'sheart rate was 76 respiratory rate 12 blood pressure152/81 initial weight 199 pounds. General: Obese. Skin:Facial scars. HEENT: Pupils equal round and reactive tolight and accommodation
extraocular movements
DISEASE
intact. Neck:Positive murmur radiating to right neck. Chest: Bibasilarcrackles. Heart: Regular rate and rhythm Admission Date: [**2195-2-5**] Discharge Date: [**2195-5-28**]Date of Birth: [**2120-5-13**] Sex: FService:This is an addendum to the discharge summary for the days[**2-5**] to [**5-28**].During the month of [**Month (only) 958**] the patient progressed withphysical therapy and treatments of her
infections
DISEASE
withantibiotics and good nutrition. At the end of [**Month (only) 958**] thepatient had a IJ Perm-A-Cath placed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].The patient tolerated the procedure well and was transportedback to the CSRU in stable condition. During this time thepatient was fed using a post pyloric tube while keeping thenasogastric tube to suction to allow closure of
enterocutaneous fistula
DISEASE
. Toward the end of [**Month (only) 958**] thenasogastric tube was removed. Dr. [**Last Name (STitle) 957**] on the [**4-18**] placed a feeding jejunostomy tube. The patienttolerated the procedure well and was transported back to theCSRU in stable condition. Following surgery the patient wasrestarted on the tube feeds Nepro 40 cc with 110 grams ofProMod q.d. The patient continued to progress during herhospital stay and it was decided that the patient would beable to be discharged to rehabilitation services for furtherphysical therapy.On the [**4-26**] it was decided that the patient will beable to be transferred to rehabilitation services.DISCHARGE PHYSICAL EXAMINATION: Temperature max 99.6 99.2.76 123/36 1000 in 15 cc out in urine. Discharge weight is86 kilograms which is down 4 kilograms from preoperativeweight of 90 kilograms. She is on CPAP 15 700 12 5 and50%. The patient had Pseudomonas and Klebsiella in hersputum and enterococcus in the urine. ID was consulted. Theidea was that Enterobacter would not be covered and that thePseudomonas and Klebsiella would be treated with Tobramycinfollowing verification of infiltrates on a CT scan. Thepatient on the [**4-25**] had a scan which showed a leftlower lobe collapse most likely
pneumonia
DISEASE
.DISCHARGE DIAGNOSES:1. Status post coronary artery bypass graft and AVR.2. Status post PEG tube placement.3. Status post drainage of
abscess
DISEASE
at the PEG tube site withan enterocutaneous
fistula
DISEASE
.4. End stage
renal disease
DISEASE
. Status post dialysis catheterplacement.5. Status post percutaneous trach placement.6. Status post J tube placement.7.
Pneumonia
DISEASE
multiple episodes during hospitalization stay.8. Right lower leg
infection
DISEASE
with a V.A.C. placement.9. Chest wound
infection
DISEASE
status post V.A.C. placement.SECONDARY DIAGNOSES:1. Insulin dependent
diabetes mellitus
DISEASE
.2. Hypertension.3. Increased cholesterol.4. Skin
cancer
DISEASE
of the face.5.
Sleep apnea
DISEASE
.6. Abdominal hernia ventral.7. Uterine cancer status post radiation.8. Vertigo.9. Osteoarthritis.10. Obesity.DISCHARGE CONDITION: Stable to rehabilitation services.DISCHARGE MEDICATIONS:1. Tobramycin 100 mg intravenous q hemodialysis timesfourteen days. Please check Tobramycin levels withhemodialysis.2. Regular insulin sliding scale 121 to 150 3 units 151 to200 6 units 201 to 250 9 units 251 to 300 12 units 301 to350 call primary care physician.3. Lantus 30 units subQ at 8:00 p.m.4. Metoclopramide 10 mg intravenous q.h.s.5. Sertraline 100 mg po q.d.6. Lansoprazole 30 mg po b.i.d.7. Amiodarone 400 mg po q.d.8. Tylenol 650 mg po q 6 hours prn.9. Epogen [**Numeric Identifier 961**] units three times a week.10. Colace 100 mg po b.i.d.11. Albuterol one to two puffs po q 4 to 6 hours prn.12. Miconazole powder 2% topical q.i.d. prn.13. Ipratropium bromide two puffs inhaler q 4 hours prn.14. Bisacodyl 10 mg per rectum q.h.s.DIET: ProMod 110 grams per day and Nepro 2/3 strength at 50cc an hour continuously.TREATMENTS: The patient should continue with aggressivephysical therapy and chest physical therapy. The patientshould receive chest physical therapy q four hours. Thepatient should have trach trials with 50% FIO2 four hours aday at 8:00 a.m. 2:00 p.m. and 7:00 p.m. The patient shouldhave V.A.C. dressing changes to the chest and to the rightlower extremity once a week. At that time the wound shouldbe evaluated. The patient should also have J tube care.Until the first follow up with Dr. [**Last Name (STitle) 957**] the dressings forthe J tube should not be changed. The upper wound and lowerwound on the abdomen should have dry dressing changes. Thepatient should continue with trach care. The patient willrequire laboratories with hemodialysis and Tobramycin levelswith hemodialysis. The patient will follow up with Dr.[**Last Name (STitle) 70**] in roughly two weeks Dr. [**Last Name (STitle) 962**] in four weeks andDr. [**Last Name (STitle) 957**] in two weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] M.D. [**MD Number(1) 75**]Dictated By:[**Last Name (NamePattern4) 959**]MEDQUIST36D: [**2195-5-28**] 08:37T: [**2195-5-28**] 08:47JOB#: [**Job Number 963**]Admission Date: [**2195-6-6**] Discharge Date: [**2195-6-19**]Date of Birth: [**2120-5-13**] Sex: FService: Cardiothoracic SurgeryCONTINUATION:DISCHARGE MEDICATIONS:1. Sertraline 150 mg per jejunostomy tube q.d.2. Lantus insulin 30 units subcutaneous q.p.m.3. Prevacid 30 mg elixir via jejunostomy tube q.d.4. Epogen 10000 units IV three times weekly with dialysistreatments.5. Heparin 5000 units subcutaneously q. 6 hours.6. M.V.I. 5 mL via jejunostomy tube q.d.7. Zinc sulfate 220 mg via jejunostomy tube q.d.8. Vancomycin 250 mg solution via jejunostomy tube q. 6 hoursfor her
C. difficile
DISEASE
.9. Amiodarone 200 mg via jejunostomy tube q.d.10. Flagyl 500 mg IV q. 12 hours also for
C. difficile
DISEASE
.11. Vitamin C 500 mg via jejunostomy tube q.d.12. Reglan 10 mg IV q. 12 hours.13. Percocet 5/325 one to two tablets via jejunostomy tube q.4 hours p.r.n.14. The patient is on vancomycin 1 gram IV to be dosedaccording to a level prior to dialysis treatments. Thepatient should be dosed with 1 gram IV for a level less than15.15. The patient is receiving tobramycin 70 mg IV withdialysis dosing and should have her tobramycin levelschecked. She should be redosed with tobramycin when herlevel falls below 1.5 that is a trough level.TREATMENT REQUIRED UPON DISCHARGE:1. The patient receives wet-to-dry normal saline dressings toher right lower extremity wounds as well as her abdominalwound t.i.d.2. The patient has a V.A.C. dressing in her open sternalwound which should be changed twice weekly. It was mostrecently changed on Thursday [**6-18**].3. The patient is being tube fed via her jejunostomy tubefull-strength Impact with fiber at 70 mL per hour.4. The patient's current ventilator settings are CPAP withpressure support of 5 and PEEP of 5 and FIO2 of 50%. She mayhave a Passey-Muir valve p.r.n. to speak. She should haveassistance from the speech therapy department to assist herwith speaking with her tracheostomy.CONDITION ON DISCHARGE: Fair.DISCHARGE DIAGNOSES:1. Sternal wound
infection
DISEASE
status post cardiac surgerystatus post limited sternal wound debridements on [**2195-6-9**].2.
End-stage renal disease
DISEASE
.3.
Respiratory failure
DISEASE
.4. Clinical
depression
DISEASE
.5. Insulin dependent
diabetes mellitus
DISEASE
. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] M.D. [**MD Number(1) 75**]Dictated By:[**Name8 (MD) 964**]MEDQUIST36D: [**2195-6-19**] 12:13T: [**2195-6-19**] 12:33JOB#: [**Job Number 965**]Admission Date: [**2195-6-6**] Discharge Date: [**2195-6-22**]Date of Birth: [**2120-5-13**] Sex: FService: CardiothoracicHISTORY OF PRESENT ILLNESS: This is a 75-year-old femalepatient who had a very prolonged previous hospitalization atthe [**Hospital1 69**] and was ultimatelydischarged on [**2195-5-28**]. During her hospitalizationshe underwent coronary artery bypass graft x4 with an aorticvalve replacement. Her postoperative course was complicatedby aspiration wound
infection
DISEASE
of her sternal wound as wellas of her saphenectomy gastrostomy tube placement followedby
necrosis
DISEASE
of the abdominal wall as well as
acute renal
failure
DISEASE
. Please see discharge summary from thathospitalization for details of her postoperative course afterher cardiac surgery.The patient was readmitted to the hospital on [**2195-6-6**]due to
fevers
DISEASE
to 103 at the rehabilitation facility despitebeing on intravenous antibiotics. In the EmergencyDepartment the patient was noted to have a fair amount ofpurulent drainage in the open sternal wound. The patient wasadmitted to the Surgical Intensive Care Unit at that time.PAST MEDICAL HISTORY:1.
Coronary artery disease
DISEASE
status post coronary artery bypassgraft as previously noted with an aortic valve replacementfor
aortic stenosis
DISEASE
.2.
End-stage renal disease
DISEASE
. The patient is hemodialysisdependent.3.
Hypertension
DISEASE
.4. Insulin dependent-diabetes
mellitus
DISEASE
.5.
Sleep apnea
DISEASE
.6.
Vertigo
DISEASE
.7.
Osteoarthritis
DISEASE
.8.
Skin cancer
DISEASE
in the past.9.
Abdominal hernia
DISEASE
repair.10.
Uterine cancer
DISEASE
status post total abdominal hysterectomy.11. Obesity.MEDICATIONS ON ADMISSION TO THE HOSPITAL:1. Tobramycin.2. Vancomycin.3. Reglan.4. Protonix.5. Amiodarone.6. Zoloft.7. Compazine.ALLERGIES: No known drug
allergies
DISEASE
.PHYSICAL EXAMINATION ON ADMISSION TO THE HOSPITAL: Thepatient was awake and responsive following commandsappropriately. She was on a ventilator via tracheostomy.HEENT was unremarkable. Her lungs were clear to auscultationbilaterally. Patient was tachycardic with a regular rateand rhythm. Her abdomen was soft obese nontender andnondistended.LABORATORY VALUES UPON ADMISSION TO THE HOSPITAL: Whiteblood cell count of 10000 hematocrit of 32 platelet countof 201. Sodium of 148 potassium 3.3 chloride 110 CO2 21BUN 42 creatinine 3.7 glucose of 277.Patient initially had an echocardiogram which revealed a leftventricular ejection fraction of 60% and moderate tricuspidregurgitation.Chest x-ray on admission to the hospital revealed a smallleft
pleural effusion
DISEASE
and questionable
congestive heart
failure
DISEASE
pattern.It was noted that the patient's Vancomycin and tobramycinlevels were quite low upon admission to the hospital and shewas restarted on both of those medications.On [**6-7**] hospital day two the patient underwent aPlastic Surgery consultation due to persistent sternal wound
infection
DISEASE
which had previously been healing now showingsigns of
infection
DISEASE
. Patient was also noted to have
Clostridium difficile colitis
DISEASE
for which she had been placedon intravenous Flagyl.The patient was ultimately taken to the operating room on[**2195-6-9**] after transesophageal echocardiogram theprevious day ruled out
endocarditis
DISEASE
. In the operating roomthe patient underwent a limited sternal wound debridement anddrainage of some fluids at the inferior portion of her wound.Postoperatively the patient returned to the SurgicalIntensive Care Unit where she has had problems withintermittent
hypotension
DISEASE
requiring IV Neo-Synephrine drip.Patient continued on tube feeds via her jejunostomy tubewhich was previously placed during her previous admissionwhich she had been tolerating well. She was still on theventilator on varying levels of pressure support in the CPAPmode which she had tolerated well on 50% FIO2.Patient received a few units of packed red blood cells overthe course of the next few days due to drifting hematocrit.Patient's sternal wound had remained clean and ultimately aVAC dressing was placed in the sternal wound area on [**2195-6-18**]. The patient was maintained on 3x a week hemodialysistreatments on Monday Wednesday Friday and has beentolerating those treatments well. Patient's pressure supportwas ultimately weaned from 12 to 5 and she has remained onpressure support of 5 for the past few days with an FIO2 of50% and a PEEP of 5 as well and has remained stable on thoseventilator settings.The patient has had short bouts of trache mask trials butdoes get
tachypneic
DISEASE
after approximately 30 minutes. Patientalso required bedside repositioning of her jejunostomy tubewhich was done in the Intensive Care Unit successful with nosequelae from that patient. The patient has remained withstable hemodynamic parameters. Has been tolerating her tubefeeds has remained on minimal ventilator supports and sheis ready to be transferred to rehabilitation facility toprogress with Physical [**Hospital 966**] rehabilitation and ultimateweaning from a ventilator.The patient's condition day on [**2195-6-19**] is as follows:temperature is 99.0 heart rate is 88 in normal sinus rhythmrespiratory rate varies from 18-24. Her blood pressure is114/46. On the ventilator the patient is in a CPAP modewith 5 of PEEP 5 of pressure support and 50% of O2 with amost recent blood gas being 7.41 41 73 27. Otherlaboratory values from today [**6-19**] are as follows: Whiteblood cell count 5.6 hematocrit of 35.8 platelet count of206. PT 13.9 INR 1.3 PTT 29.9 sodium 132 potassium 5.3chloride 99 CO2 24 BUN 64 creatinine 3.6 glucose 124.Patient's most recent chest x-ray was on [**2195-6-8**] whichshowed a
chronic left pleural effusion
DISEASE
.Most recent cultures include a sputum culture from [**6-8**]which revealed MRSA Pseudomonas as well as Serratia.Patient is previously cultured MRSA from both her leg woundand her sternal wound. Stool on [**6-10**] is positive for
Clostridium difficile
DISEASE
. Urine on [**6-12**] is positive forproteus and enterococcus and her sternal wound swab on [**6-9**] had rare growth of diphtheroids.Physical examination today: The patient is awake alert andresponsive. She has
coarse breath sounds
DISEASE
bilaterally. Herchest wound is clean with a VAC dressing in place. Herabdomen is soft obese and nontender. Her extremities arewith 2Admission Date: [**2195-6-29**] [**Year (4 digits) **] Date: [**2195-7-2**]Date of Birth: [**2120-5-13**] Sex: FService:ADMISSION DIAGNOSES: 1)
Anoxic
DISEASE
brain injury. 2) End-stage
renal disease
DISEASE
on hemodialysis. 3) Sternal wound. 4)
Diabetes
DISEASE
. 5)
Respiratory distress
DISEASE
.HISTORY OF PRESENT ILLNESS: The patient is a 75-year-oldfemale status post a long hospitalization at [**Hospital1 18**]culminating in CABG x 4 porcine AVR aspiration
infection
DISEASE
sternal wound infection saphenous vein site infectionstatus post a G-tube with
abdominal wall necrosis
DISEASE
statuspost J-tube
ARF
DISEASE
requiring hemodialysis. The patienteventually discharged on [**2195-5-28**]. Then readmitted on[**2195-6-6**] for
fever
DISEASE
to 103. In
VICU
DISEASE
for sternal wound
infection
DISEASE
and transferred to [**Hospital **] Rehab.At [**Hospital1 **] two days prior to admission per report thepatient had a
PEA arrest
DISEASE
status post epinephrine. Thepatient went into V-fib arrest status post 100 mg joule
shock
DISEASE
which converted into A-fib. The patient wastransferred to [**Hospital 8**] Hospital late PM on [**2195-6-28**]. Thepatient there was continued on vent. Chest x-ray and CTshowed a bilateral lower lobe consolidation and left upperlobe consolidation. The [**Year (4 digits) **] report from [**Hospital 8**]Hospital attributed mucous plugging and vent associated
pneumonia
DISEASE
leading to
PEA arrest
DISEASE
. Also contributing wereelements of
hyperkalemia hypoxia
DISEASE
and
hypovolemia
DISEASE
.The patient had initially had episodes of
SVT
DISEASE
in the 70s-90swhich responded to 250 of normal saline. The patientremained in
atrial fibrillation
DISEASE
and spontaneously convertedto sinus. She was transferred to [**Hospital1 18**] for continuity ofcare.PAST MEDICAL HISTORY: 1)
Coronary artery disease
DISEASE
statuspost CABG x 4 - LIMA to LAD SVG to diagonal SVG to OMsequential 2) AVR porcine 3) End-stage
renal disease
DISEASE
onhemodialysis 4)
Diabetes
DISEASE
5)
OSA
DISEASE
6)
OA
DISEASE
7)
Vertigo
DISEASE
8) Skin
cancer
DISEASE
9) History of
abdominal hernia
DISEASE
repair 10) Uterine
cancer
DISEASE
status post
TAH
DISEASE
11)
Obesity
DISEASE
12)
Hypertension
DISEASE
13)Status post esophageal dilatation 14) Status post gastricbypass with
ventral hernia
DISEASE
15) High cholesterol.MEDS ON TRANSFER: 1) prevacid 2) Reglan 3) Zofran 4)iron 5) zinc sulfate 6) amiodarone 7) Vitamin C 8)tobramycin 9) vancomycin 10) heparin 11)................... 12) epogen.ALLERGIES: No known
drug allergies
DISEASE
.SOCIAL HISTORY: The patient is a rehab patient at [**Hospital1 **].She has three sons.FAMILY HISTORY: Mother and grandmother died of
diabetes
DISEASE
.
EXAM
DISEASE
: Temperature 101 heart rate 85 blood pressure 103/42respiratory rate 44 98% on vent IFMV 600x14 FIO2 0.5pressure support 10 PEEP 5. General - an elderly womanchronically ill in no acute distress. HEENT - pupilsequally round and reactive to light minimally. OP - mucousmembranes moist evidence of some EOMI. In general patientnot responsive. Neck - trach no JVD. Lungs - crackles atthe left lower zone. Cardiovascular - regular rate and
rhythm systolic murmur I/VI ejection murmur
DISEASE
. Abdomen -positive bowel sounds nontender nondistended. Evidence ofsternal wound draining suctioned with VAC. Evidence of aJ-tube entrance of a ventral
hernia
DISEASE
wound and evidence of awound under the left breast. Extremities - left heel eschar.Right leg saphenous vein site erythematous. Neuro - patientgrimaces to sternal rub does not follow commands. She haspositive Snell positive grasp. No decreased deep tendonreflexes in lower extremities. Babinski equivocal.LABS FROM [**6-29**] FROM [**Hospital1 **]: White blood cell count 12hematocrit 35.9 platelets 209 N 87 L 8 M 3 E 1.Electrolytes - 128/5.7 102/20 47/3.5 243. CT of the headshowed no bleed. CT of the chest showed left upper lobeinfiltrate bilateral
pleural effusions
DISEASE
and bilateralconsolidation. ABG - 7.26 45 91 INR 1 T4 5.4 ALT 11AST 21 alk phos 165 total bili 0.7.LABS AT [**Hospital1 18**] [**6-29**]: White blood cell count 8.5 hematocrit31.9 platelets 193 N 86 L 8 M 5. Electrolytes - sodium144 K 3.3 chloride 107 bicarb 27 BUN 27 creatinine 2.5platelets 150 lactate 1.4 ..................... ABG -7.42 45 109 on FIO2 of 50%. Tobra level and vanc levelpending.HOSPITAL COURSE: Please see previous [**Hospital1 18**] hospitalizationsummaries. Outside hospital [**Hospital1 8**] report head CT -
chronic degenerative
DISEASE
changes. On [**6-29**] chest CT report - noPE bilateral lower lobe consolidation effusions left upperlobe consolidation. Echo from [**6-8**] - LVEF of greater than55% RV function reduced mild MR.ASSESSMENT AND PLAN: The patient was a 75-year-old womanwith
coronary artery disease
DISEASE
CABG
end-stage renal disease
DISEASE
diabetes
DISEASE
status post a
PEA arrest
DISEASE
V-fib A-fib now insinus likely secondary to
hypoxia hyperkalemia
DISEASE
.1) CARDIAC - Status post arrest. Patient with history ofarrest. The patient was ruled out by enzymes. The arrestwas likely a combination of
hypoxia
DISEASE
and mucous plugging aswell as metabolic with possible
hyperkalemia
DISEASE
and
hypercalcemia
DISEASE
. The patient has a history of a normal echo.The patient's rhythm was in sinus. The patient was continuedon 200 mg po qd. The patient placed on telemetry andmonitored in the MICU. Monitored electrolytes and in's andout's. The patient remained stable throughout herhospitalization. The patient's sternal wound placed to VAC.2) PULMONARY: Patient with a history of being vent and trachdependent. Patient treated with vanc tobra ceftaz andFlagyl given history of vent-associated given history ofantibiotic resistant organisms. Sputum showed gram-negativerods. We will await final sensitivities from sputum. Thepatient's O2 sats remained stable throughout herhospitalization.3) RENAL: Patient with
end-stage renal disease
DISEASE
onhemodialysis. The patient obtained hemodialysis in-house.4) ENDOCRINE: Patient with
diabetes
DISEASE
on sliding scale. Thepatient was maintained on sliding scale. Thyroid level waschecked and normal.5) ID: Patient had one episode of being
febrile
DISEASE
on [**6-30**].The patient since then afebrile. The patient's blood urinesputum cultures pending. Patient with several wounds
nonhealing
DISEASE
in nature. The patient had no evidence of activepus or drainage from any of the sites. The patient's sternalwound is set to the VAC.6) NEURO: Patient evaluated by neuro in-house given changein mental status status post PEA arrest. The patient'sinitial diagnosis was most likely
hypoxic damage
DISEASE
resultingfrom hypoxic event. The patient's head CT showed no changes.MRI was obtained. EEG was obtained.7) HEME: Patient on Epogen and hemodialysis.8) FEN: The patient's electrolytes were monitored in-house.Peripheral - Patient maintained on subcu heparin Protonix.Lines - patient with left Quinton right subclavianperipherals.9) CODE: Patient remained full.PLAN: [**Month/Year (2) **] was discussed with family and PCP.[**Name10 (NameIs) **] to rehab. Patient was also seen by a social workerin-house. Patient discharged to rehab.[**Name10 (NameIs) 894**] CONDITION: Poor.[**Name10 (NameIs) 894**] DIAGNOSES: 1)
Anoxic
DISEASE
brain injury. 2) End-stage
renal disease
DISEASE
on hemodialysis. 3)
Diabetes
DISEASE
. 4) Status post
pulseless
DISEASE
electrical activity. [**Name6 (MD) **] [**Name8 (MD) **] M.D. [**MD Number(1) 968**]Dictated By:[**Last Name (NamePattern1) 201**]MEDQUIST36D: [**2195-7-1**] 12:17T: [**2195-7-1**] 11:52JOB#: [**Job Number 969**]Admission Date: [**2152-10-2**] Discharge Date: [**2152-10-11**]Service: MEDICINE ONCOLOGYHISTORY OF PRESENT ILLNESS: This is an 81-year-old femalewith a history of metastatic
melanoma
DISEASE
with known metastasesto the liver and lung who status post resection in the 90swith recurrence in [**2146**] status post treatment with Taxol.She presented to the Emergency Room on [**2152-10-3**]with altered mental status decreased p.o. intake
confusion
DISEASE
and
headache
DISEASE
over several weeks and was found to have threemass lesions in her brain on head CT.The patient was started on Decadron as well as Dilantin. Inthe Emergency Room she became
hypertensive
DISEASE
and was sent tothe SICU. She was maintained on Nipride GTT.In the Intensive Care Unit the patient was weaned offNipride and then changed to Labetalol Hydralazine. The patientwas also noted to have
cellulitis
DISEASE
on her left knee and wasinitially maintained on Vancomycin and later changed to Keflex.The patient was also evaluated by Radiation/Oncology and itwas decided that the patient would received a total of seventreatments of whole brain radiation therapy in conjunctionwith Decadron as well as Dilantin.During her Intensive Care Unit stay the patient hadincreased alertness and was more oriented although she doeshave a history of baseline
dementia
DISEASE
.PAST MEDICAL HISTORY: Metastatic
melanoma
DISEASE
status postresection in [**2138**] with recurrence in [**2146**] status posttreatment with Taxol. History of paroxysmal atrial
fibrillation
DISEASE
with anticoagulation in the past. Status postPCM for
sinoatrial dysfunction
DISEASE
. History of coronary arterydisease status post
myocardial infarction
DISEASE
in [**2143**]. MIBI in[**2152-6-23**] showed an ejection fraction of 50%. History of
hypercholesterolemia
DISEASE
. History of
hypertension
DISEASE
osteoarthritis cellulitis
DISEASE
. Status post skin graft. Peptic
ulcer disease
DISEASE
. History of
bladder cancer
DISEASE
. Chronic renalinsufficiency.ALLERGIES: AMOXICILLIN OXACILLIN AND PERCOCET REACTIONSUNKNOWN.MEDICATIONS ON ADMISSION: Imdur 30 mg Warfarin Lasix 20q.d. Calcium Carbonate 1500 q.d. Vitamin D 4000 q.d.Colace 100 mg b.i.d. Protonix 40 q.d. Dietrol 2 mg b.i.d.Labetalol 300 mg b.i.d. Lipitor 10 mg p.o. q.d.SOCIAL HISTORY: The patient is a home health aide. Husbanddied three months ago. She walks but recently was unable todo so. She otherwise has a very close family.FAMILY HISTORY: On maternal side there is a history of
diabetes
DISEASE
as well as
hypertension
DISEASE
.PHYSICAL EXAMINATION: Vital signs: Temperature 96.5Admission Date: [**2195-8-12**] [**Year (4 digits) **] Date: [**2195-8-15**]Date of Birth: [**2120-5-13**] Sex: FService: MICUCHIEF COMPLAINT: Sepsis.HISTORY OF PRESENT ILLNESS: The patient is a 75 year oldfemale with an extremely complicated past medical historyincluding coronary artery bypass graft times four atrialventricular valve replacement in [**1-12**] and a precipitouslydifficult postoperative course. The patient has never beenweaned from her ventilator and has had multiple ventilatorassociated
pneumonias
DISEASE
particularly most recently withpseudomonas Serratia and Klebsiella. The patient has endstage
renal disease
DISEASE
and history of
gastrointestinal bleed
DISEASE
secondary to
gastritis
DISEASE
and
esophagitis
DISEASE
.Most recently the patient was discharged from this hospitalto rehabilitation in early [**Month (only) 547**] only to come back with
fevers
DISEASE
and ultimately grew out Methicillin resistantStaphylococcus aureus wound
infection
DISEASE
requiring debridementon [**2195-5-28**]. The patient returned to rehabilitation[**2195-6-22**] where she sustained a
pulmonary embolus arrest
DISEASE
received Epinephrine and electrical conversion. The patientwas noted to have decreased responsiveness post codeattributed to
anoxic
DISEASE
brain injury per neurology. She wastransferred back to [**Hospital **] Rehabilitation where sheunderwent vigorous physical therapy.On [**2195-8-1**] per family she had a
fever
DISEASE
of 103 with cultureperipherally and from her dialysis catheter. Both grew outMethicillin resistant Staphylococcus aureus. The patient wasstarted on a course of Vancomycin with only low gradetemperature. She became lethargic on [**2195-8-9**] and wasunable to tolerate hemodialysis due to
hypotension
DISEASE
systolicblood pressure in the 70s. The patient briefly improvedpostdialysis on [**2195-8-10**] as did her mental status but thenbecame increasingly lethargic with heart beats in the 130sblood pressure 80 over palpable and was transferred over to[**Hospital1 69**] for further management.On arrival the patient was noted to be extremely
febrile
DISEASE
hypotensive tachypneic
DISEASE
. The patient received an A line andright internal jugular central line for monitoring and fluidresuscitation. The patient's course was complicated by herpoor toleration of hemodialysis secondary to
hypotension
DISEASE
andwas started on pressors of Levophed and ultimately requiredan addition of vasopressor. The patient was becomingincreasingly somnolent and had not defervesced at this timedespite the addition of multiple antibiotic therapy FlagylCeftriaxone Vancomycin and Tobramycin.CT of the abdomen and chest showed no frank abscess or fluidcollection. Flagyl was ultimately discontinued as decreasedprobability of anaerobic
infection
DISEASE
. Cultures at outsidehospital showed multidrug resistant organisms includingMethicillin resistant Staphylococcus aureus. Transesophagealechocardiogram was obtained to rule out
endocarditis
DISEASE
and itwas negative showing ejection fraction of 55%. Left Hickmancatheter with [**Hospital1 **] as probable source of
infection
DISEASE
.Foley was placed at this time. The patient was anuric yet10cc of purulent material was noted. The patient was nowgrowing gram positive cocci in pairs and clusters from twodifferent sites the Hickman and/or previous PICC line. Shewas increasing her pressor requirement and was
hypotensive
DISEASE
despite two liters of fluid.She was started on Dopamine in addition to her Levophed andvasopressors. Throughout the day the patient's systolicblood pressure decreased to the 80/30. By [**2195-8-14**] she wasback on EC vent control. The patient was noted at 3:43 a.m.on [**2195-8-15**] to have an episode of
asystole
DISEASE
. The family wasat bedside as well throughout the night. The pupils werenoted to be fixed and dilated and unresponsive. Ventilationwas discontinued and spontaneous respirations were notobserved. The patient was declared dead at 3:43 a.m. Thefamily declined autopsy. DR.[**Last Name (STitle) 970**][**First Name3 (LF) 971**] 12-888Dictated By:[**Last Name (NamePattern1) 972**]MEDQUIST36D: [**2195-8-15**] 11:51T: [**2195-8-18**] 20:47JOB#: [**Job Number 973**]Admission Date: [**2177-8-20**] Discharge Date: [**2177-8-26**]Date of Birth: [**2121-10-22**] Sex: FService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 974**]Chief Complaint:
Diarrhea
DISEASE
X 2.5 weeks
abdominal pain fatigue
DISEASE
Major Surgical or Invasive Procedure:[**2177-8-20**]: Right-sided internal jugular venous catheterHistory of Present Illness:55 year-old female presents with 2/5 week history of non-bloody
diarrhea
DISEASE
. Patient states that
diarrhea
DISEASE
is often preceeded byright and left lower quadrant cramping and discomfort. Symptomsare relieved with voiding and evucation. She denies
fever
DISEASE
nausea
DISEASE
and/or
emesis
DISEASE
. She reports two episodes of
chills
DISEASE
. Shepresents today with
fatigue
DISEASE
. She denies
abdominal distension
DISEASE
orhematesis.
Denies urinary symptoms
DISEASE
. She was recently seen by herPrimary Care Physician for evaluation of
diarrhea
DISEASE
and by reportstool O&P cultures were negative.Past Medical History:
Seizure disorder
DISEASE
Insulin Dependent
Diabetes Mellitus
DISEASE
(x4 years on Lantus)
Vitiligo
DISEASE
[**2170**]:
Stiff person syndrome
DISEASE
treated with Valium
hypercholesterolemia
DISEASE
Bronchitis
DISEASE
Anemia
DISEASE
Constipation
DISEASE
.
PSH
DISEASE
D&C
Pyloric stenosis
DISEASE
at age 6 weeksSocial History:Works in human resources: Department of
Labor
DISEASE
for the StateDenies tobacco ETOH IV drug useIndependent in activites of daily livingUse of assistive devices at homeAdmission Date: [**2151-5-25**] Discharge Date: [**2151-5-31**]Service: MEDICINE
Allergies
DISEASE
:DemerolAttending:[**First Name3 (LF) 983**]Chief Complaint:
Lethargy
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:82 year old male with past medical history of coronary arterydisease
atrial fibrillation
DISEASE
type 2 diabetes BPH chronic
kidney disease
DISEASE
and
gout
DISEASE
who presents with intermittent
confusion
DISEASE
and high
fevers
DISEASE
. The patient is [**First Name3 (LF) 595**] speaking only generallysleepy but family (son) recounts that the patient had difficultyvoiding 6/1-2/[**2150**]. At the time he endorsed urinatingfrequently but small amounts each time (Admission Date: [**2185-10-25**] Discharge Date: [**2185-11-2**]Date of Birth: [**2120-2-23**] Sex: MService:CHIEF COMPLAINT: Dyspnea on exertion.HISTORY OF PRESENT ILLNESS: Patient is a 65-year-old manrecently evaluated for worsening
dyspnea
DISEASE
on exertion. Thepatient was first evaluated for
dyspnea
DISEASE
on exertion back in[**2183-9-28**]. At that point he was found to have mildleft
coronary artery disease
DISEASE
as well as a totally occludedright coronary artery with good collaterals. He was alsonoted to have a moderate
mitral regurgitation
DISEASE
. He wasmanaged medically for this condition.During the course of the year [**2184**] the patient notedprogressive decrease in his activity tolerance. After workup it was determined that the patient was in need of repairof his mitral valve as well as coronary artery bypassgrafting.PAST MEDICAL HISTORY:1.
Myocardial infarction
DISEASE
.2. Coronary
artery disease
DISEASE
.3. Possible
chronic obstructive pulmonary disease
DISEASE
.4. Depression.5. Hypertension.6. Hyperlipidemia.7.
Valve disease
DISEASE
.8. Remote
pleurisy
DISEASE
.9. Arthritis.10. Possible prior
CVA
DISEASE
.11. Recovered alcoholic (has not drank in 16 years).PAST SURGICAL HISTORY:1. Umbilical
hernia
DISEASE
repair.2. Cataract surgery.ALLERGIES: No known
drug allergies
DISEASE
.MEDICATIONS:1. Vistaril.2. Lipitor.3. Multivitamins.4. Aspirin.5. Escitalopram.HOSPITAL COURSE: Patient was admitted to the Medical Centeron [**2185-10-25**] and taken to surgery for coronary artery bypassgraft and mitral valve repair. Surgery was performed withoutcomplications and patient thereafter was transferred to theCSRU. Later on the day of surgery the patient received twounits of packed red blood cells for a hematocrit of 21.2.Patient required pacing through postoperative day #1 and #2to maintain an adequate heart rate. He was successfullyextubated on postoperative day #1 even though he continuedto be
wheezy
DISEASE
with significant productive
cough
DISEASE
during hisentire stay in the CSRU.The patient as stable enough for transfer to theCardiothoracic Surgery
Floor
DISEASE
late on postoperative day #2.Late on postoperative day #5 the patient went into atrial
fibrillation
DISEASE
. His heart rate was eventually successfullycontrolled with Metoprolol and Amiodarone. The patient hadperiods of persistent
tachycardia
DISEASE
during postoperative day#6. Decision was made to initiate anticoagulation withheparin as well as Coumadin. The patient remained stable andwithout complaints during postoperative day #7.On postoperative day #8 the patient was deemed stable fordischarge to home. The decision was made to discontinue thepatient's Amiodarone prior to discharge given decrease in hisheart rate to the 50s. He remained in sinus rhythm.Following discharge it was planned the patient would receivea visit from a visiting nurse two days following dischargefor an INR check. The results of the INR check was to befaxed to the patient's cardiologist. The patient was to callhis cardiologist on discharge day #2 for instructions onfurther Coumadin doses. The patient was to take 10 more daysof Lasix following discharge since he was still significantlyabove his admission weight.CONDITION ON DISCHARGE: Stable.DISCHARGE MEDICATIONS:1. Metoprolol 25 mg p.o. b.i.d.2. Escitalopram 10 mg p.o. q.d.3. Atorvastatin 200 mg p.o. q.d.4. Percocet.5. Enteric coated aspirin 325 mg p.o. q.d.6. Potassium Chloride 20 mEq p.o. b.i.d.7. Lasix 40 mg p.o. b.i.d.8. Coumadin 5 mg p.o. q.d. times two days.FO[**Last Name (STitle) 996**]P:1. Patient is to follow up with Dr. [**Last Name (Prefixes) **] in clinicfour weeks following discharge.2. Patient was to contact his cardiologist's office two daysfollowing discharge for further guidance on his Coumadindosing as well as to schedule a follow up appointment.3. The patient was to contact his primary care physician'soffice for a follow up appointment in approximately threeweeks. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**] M.D. [**MD Number(1) 414**]Dictated By:[**Name8 (MD) 997**]MEDQUIST36D: [**2185-11-2**] 14:20T: [**2185-11-2**] 14:37JOB#: [**Job Number 998**]Admission Date: [**2186-2-4**] Discharge Date: [**2186-2-21**]Date of Birth: [**2126-9-17**] Sex: FService: NEUROLOGY
Allergies
DISEASE
:Haldol / Prozac / Paxil / Sinemet CrAttending:[**First Name3 (LF) 1032**]Chief Complaint:FTTMajor Surgical or Invasive Procedure:PEG placementHistory of Present Illness:The pt is a 59 year-old right-handed with progressivelyworsening
stiffness weakness
DISEASE
and
dysarthria
DISEASE
since [**2183**] who issent in from her rehab for generalized weakness decline anddifficulty eating. The patient is followed by Dr. [**First Name (STitle) 951**] in the
movement disorders
DISEASE
division who notes an extensive negativeworkup in his most recent assessment of [**2186-1-10**] (see below).Perthe record the stiffness started after a fall on ICE in [**2183**].Shewas admitted 7/21-26/07 for left leg
dystonia
DISEASE
. Possibleetiologies considered at that time included
hereditary spastic
DISEASE
paraparesis Parkinsons
DISEASE
and multiple systems
atrophy
DISEASE
. Littleevidence could be found for any of these disorders.An new EMG today demonstrated a generalized moderately severechronic and ongoing
disorder of motor neurons
DISEASE
or their axons.The patient has been on tizanidine flexeril baclofen sinemetand artane - none with particularly significant effect.Past Medical History:
depression
DISEASE
rotator cuff injury
osteopenia
DISEASE
colectomyappendectomyPer Dr.[**Name (NI) 1033**] [**2186-1-10**] note:Admission Date: [**2124-4-24**] Discharge Date: [**2124-5-3**]Service: Cardiothoracic SurgeryHISTORY OF PRESENT ILLNESS: This is an 84-year-old malereferred to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] for evaluation of surgicaloptions for severe
aortic stenosis
DISEASE
and coronary arterydisease.The patient experienced a near-syncopal episode in [**2124-1-8**]Admission Date: [**2143-3-10**] Discharge Date: [**2143-3-29**]Date of Birth: [**2097-8-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:Bactrim Ds / IndomethacinAttending:[**First Name3 (LF) 1055**]Chief Complaint:
Shortness of breath
DISEASE
Major Surgical or Invasive Procedure:1) Intubation with mechanical ventilation2) BronchoscopyHistory of Present Illness:45 yo man with h/o HIV who p/w 4 days of
cough
DISEASE
productive ofbrown sputum as well as left sided pleuritic CP. He denied
hemoptysis N/V
DISEASE
or
abdominal pain
DISEASE
.*In the ED the patient became hypoxic with an O2 sat of 80% on
RA
DISEASE
which improved to 91% on NRB. He was also tachypneic. Thepatient was intubated. He was tachy to the 130's BP 133/75with a lactate of 4.0. Patient became
hypotensive
DISEASE
at 70/35after intubation/sedation. Levophed was started. Unable toadequately sedate on Propofol gtt.Past Medical History:HIV/AIDS (CD4Admission Date: [**2144-2-4**] Discharge Date: [**2144-2-7**]Date of Birth: [**2097-8-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:Bactrim Ds / Indomethacin / Ciprofloxacin / LinezolidAttending:[**First Name3 (LF) 30**]Chief Complaint:productive
cough
DISEASE
night sweats
fevers
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:Pt is a 46 yo M with hx of HIV/AIDS (last CD4 204 VL 40600 on[**2143-12-12**] not on HAART)
Hepatitis C peripheral neuropathy
DISEASE
with
chronic pain
DISEASE
on narcotics contract who now presents with 3 weekhistory of decreased po intake malaise night sweats fatigueproductive
cough
DISEASE
of green sputum chills. He also states thathe developed
chest pain
DISEASE
on his right side worse with deepinspiration and with coughing. Admission Date: [**2195-6-29**] Discharge Date: [**2195-7-6**]Date of Birth: [**2120-5-13**] Sex: FService:ADDENDUM: 1. Neurological: The patient had an MRI and EEGto evaluate neurologic status status post anoxic braininjury. The EEG showed diffuse
encephalopathy
DISEASE
and the MRIshowed no severe
edema
DISEASE
. The patient's neurologic statusimproved during her hospital course. The patientspontaneously opened her eyes was able to slightly move herextremities and interact with the family.2. Renal: The patient continued on hemodialysis throughouther hospitalization course.3. Fever/infectious disease: The patient has a history ofrecurrent line and wound
infections
DISEASE
. The patient's sputumgrew Serratia and Pseudomonas sensitive to meropenem andtobramycin respectively.4. GI: The patient has a J-tube and she was continued ontube feeds throughout her hospitalization.5. Hematology: The patient's hematocrit remained stable.6. Access: A PICC line was placed. Her arterial line andcentral line were removed. The retains her Quinton.7. Wound: The patient was monitored by plastic surgery. Herwound dressing was changed in house on [**2195-7-4**]. [**Name6 (MD) **] [**Name8 (MD) **] M.D. [**MD Number(1) 968**]Dictated By:[**Last Name (NamePattern1) 201**]MEDQUIST36D: [**2195-7-6**] 08:46T: [**2195-7-6**] 09:07JOB#: [**Job Number 1086**]Admission Date: [**2145-12-9**] Discharge Date: [**2145-12-16**]Date of Birth: [**2097-8-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:Bactrim Ds / Indomethacin / LinezolidAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:found downMajor Surgical or Invasive Procedure:IntubatedAdmission Date: [**2194-7-18**] Discharge Date: [**2194-7-25**]Date of Birth: [**2123-12-24**] Sex: FService: MEDICINE
Allergies
DISEASE
:Atorvastatin / Penicillins / CodeineAttending:[**First Name3 (LF) 2265**]Chief Complaint:SOB decreased urineMajor Surgical or Invasive Procedure:HemodialysisPlacement of a R IJ catheterPlacement of a R subclavian tunneled dialysis lineHistory of Present Illness:Ms. [**Known lastname 2251**] is a 70yoF with h/o
dilated cardiomyopathy
DISEASE
[**1-1**]
aortic outflow obstruction
DISEASE
AICD s/p
VT
DISEASE
CAD
COPD
DISEASE
(on home O2)who presented with decreased UO and SOB now transferred frommedicine service to CCU for
hypotension
DISEASE
. Pt is currentlysomnolent and unable to provide a detailed history so detailsare obtained from OMR and Atrius records. Pt saw NP in complexcare clinic on [**7-10**] at that time felt well overall c/o dry
cough
DISEASE
but denied SOB
peripheral edema
DISEASE
. At that time her weightwas recorded at 185 lbs (dry weight is estimated at 184 lbs). On[**7-17**] she called the CCC office c/o minimal urine output (Admission Date: [**2146-1-14**] Discharge Date: [**2146-1-28**]Date of Birth: [**2097-8-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:Bactrim Ds / Indomethacin / LinezolidAttending:[**First Name3 (LF) 1070**]Chief Complaint:
seizures
DISEASE
mental status changesMajor Surgical or Invasive Procedure:Lumbar punctureHistory of Present Illness:The patient is a 48M w/ HIV/AIDS/HCV/IVDA sent from [**Hospital1 1099**] Rehab for evaluation of 2 witnessed
tonic-clonic
DISEASE
seizures
DISEASE
.
Seizures
DISEASE
occurred on evening [**2146-1-13**] lasted 30seconds - 1 minute resolved spontaneously. First
seizure
DISEASE
occured while he was being cleaned up second
seizure
DISEASE
occuredwhile family member (motherAdmission Date: [**2132-3-28**] Discharge Date: [**2132-4-9**]Date of Birth: [**2054-2-21**] Sex: MService: ORTHOPAEDICS
Allergies
DISEASE
:LevaquinAttending:[**First Name8 (NamePattern2) 1103**]Chief Complaint:Hip and
patellar fracture
DISEASE
Major Surgical or Invasive Procedure:ORIF of right patella fxORIF of right femoral neck fractureHistory of Present Illness:Briefly Mr. [**Known lastname 1104**] is a 78 year old male with extensive medicalhistory who uses a RLE prosthesis for ambulation s/p R BKA from
PVD
DISEASE
who presents s/p fall when his prosthesis slipped out ofplace found to have R patellar and non-displaced
fracture
DISEASE
ofthe R femoral neck here for possible orthopedic surgery. Hismedical problems notably include CAD s/p CABG in [**2117**] MI [**2123**]MIBI with fixed and reversible defects in [**2129**]
CHF
DISEASE
with EF 20%
PVD
DISEASE
s/p R BKA with b/l iliac stents AAA found to be 5.4 x 5.0cm on recent abdominal US paroxysmal
atrial fibrillation
DISEASE
bovine AVR and CRI on coumadin for his iliac stents and PAF.Patient reports that at baseline he is able to walk about 2blocks and activity is limited by SOB. He feels SOB gettingout of bed in the morning. He is able to climb a flight ofstairs without difficulty. He denies
orthopnea
DISEASE
or LE
edema
DISEASE
. Norecent
weight gain
DISEASE
.Past Medical History:1) CAD s/p CABG [**2117**] MI [**2123**]2) AS s/p AVR [**2123**] (bovine)3)
PVD
DISEASE
s/p R BKA and b/l iliac artery stents4)
Carotid stenosis
DISEASE
s/p R CEA5) h/o C. Diff6) h/o MRSA7)
CHF
DISEASE
class [**Last Name (LF) 1105**] [**First Name3 (LF) **] 30%8) AAA 5 x 5.4 cm9) S/P AICD10)
Hypercholesterolemia
DISEASE
11) CRI (baseline approx. 1.3)12) PAFSocial History:Lives at home alone independent. Quite smoking 8 years ago but50 pack year smoking hx.Family History:Non-contributoryPhysical Exam:98.2 68 100/48 RR15 98% on
RA
DISEASE
Gen: Cachectic appearing elderly male resting comfortably inbed appearing in
pain
DISEASE
with movement.Neck: No JVD.Cor: RR normal rate no m/r/g.Lungs: CTA b/l.Abd: NABS soft
NT/ND
DISEASE
Extr: No c/c/e. R BKA. Swollen erythematous R kneeexquisitely tender. Trace PT on the L.Pertinent Results:[**3-28**] AP LATERAL AND SUNRISE VIEWS OF THE PATELLA: No priorstudies are available for comparison. There is a horizontal
fracture
DISEASE
through the patella with 1.2 cm of displacement of thefragments anteriorly. There is a small
joint effusion
DISEASE
. There arechanges from prior BKA and extensive [**Month/Year (2) 1106**]
calcifications
DISEASE
are present.IMPRESSION: Horizontal patellar
fracture
DISEASE
with 1.2 cm ofdisplacement anteriorly.[**3-28**] PELVIS AND RIGHT HIP THREE VIEWS: There is a transverselucency through the femoral neck which may represent a
nondisplaced fracture
DISEASE
. No other
fractures
DISEASE
or
dislocations
DISEASE
areidentified. Degenerative changes of the SI and
hip joints
DISEASE
arenoted. There is diffuse demineralization. Extensive [**Month/Year (2) 1106**]
calcifications
DISEASE
and iliac stents are noted.IMPRESSION: Transverse lucency through the femoral neck whichmay represent a
nondisplaced fracture
DISEASE
.[**3-28**] CT PELVIS: There is a nondisplaced
fracture
DISEASE
of theproximal right femoral neck. No other
fractures
DISEASE
or
dislocations
DISEASE
are identified. There is diffuse
osteopenia
DISEASE
. There is a smallamount of high attenuation fluid within the right hip jointspace which may represent a small amount of
hemorrhage
DISEASE
.Extensive [**Month/Year (2) 1106**]
calcifications
DISEASE
are seen as are bilateraliliac stents. Visualized portions of the pelvis areunremarkable. Soft tissue structures are within normal limits.IMPRESSION: Nondisplaced
fracture
DISEASE
of the right femoral neck.Brief Hospital Course:78 year old male with extensive medical history notablyincluding CAD s/p CABG in [**2117**] MI [**2123**] MIBI with fixed andreversible defects in [**2129**]
CHF
DISEASE
with EF 20%
PVD
DISEASE
s/p R BKA withb/l iliac stents AAA found to be 5.4 x 5.0 cm on recentabdominal US paroxysmal
atrial fibrillation
DISEASE
who uses a RLEprosthesis for ambulation s/p R BKA who presents s/p mechanicalfall with R patellar and R femoral neck
fractures
DISEASE
here fororthopedic surgery.1) Ortho: Patient is high risk for surgery however per orthosurgery will not be extensive could be completed in relativelyshort time frame possibly under spinal anesthesia only.Awaiting
cardiolgy
DISEASE
consult for estimate of operative risk givenrecent MIBI with reversible defects in all territories and cathwith 3VD. Patient willing to accept 25-30% chance of operativemortality. [**Year (4 digits) **] has seen patient and says o.k. for surgery. Limiting factor may be INR as still 2.9 with 5 mg Vitamin K.Another 5 mg given but may need FFP/platelets and given EF30% would likely need to be done under controlled setting inICU in case of
respiratory distress
DISEASE
. [**Month (only) 116**] defer until tomorrow.Needs patellar surgery one way or another in order to ever beable to use prosthesis again.2) AAA: Seen by [**Month (only) 1106**]. Will try to get CTA duringhospitalization at some point though not now in setting ofworsened creatinine. [**Month (only) 116**] just be able to get abdominal US.Appreciate [**Month (only) 1106**] consult. Outpatient repair of AAA.3)
CHF
DISEASE
: Class [**Last Name (LF) 1105**] [**First Name3 (LF) **] 20% in past though 30% on most recentcath currently
dry
DISEASE
on exam therefore holding lasix. Ifpatient doesn't go to surgery tonight will order food and willlikely order lasix then. Also will need lasix with anyFFP/platelets.-Coumadin for goal INR [**1-10**]4)
PVD
DISEASE
: Bilateral iliac stents on coumadin therefore once INRbelow 2 will have to start heparin drip.--recheck INR post second dose of vitamin K if Admission Date: [**2179-1-29**] Discharge Date: [**2179-2-2**]Date of Birth: [**2093-2-16**] Sex: FService: MEDICINE
Allergies
DISEASE
:Sulfa (Sulfonamide Antibiotics)Attending:[**First Name3 (LF) 1115**]Chief Complaint:
respiratory distress
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:85-year-old female
atrial fibrillation schizophrenia dementia
DISEASE
presents from nursing home with
respiratory distress
DISEASE
..The patient was in her usual state of health until this AM. Atthat time she was found by nursing home staff in respiratorydistress with O2 sats of 70% on
RA
DISEASE
. EMS was contact[**Name (NI) **] and shewas started on supplemental oxygen with NRB and O2 satsresponded to 98%. She was also noted to be hot (no document oftemperature) with
cough
DISEASE
and green sputum. She was transported to[**Hospital1 18**] ED..In the ED initial vitals were: T 99.8 HR 90 BP 171/85 RR 28SaO2 98% NRB15L. EKG with
Afib
DISEASE
RVR to 130s and
LVH
DISEASE
. SBP 180s.WBC 16. BNP 12600. CXR interpreted as concerning for
CHF
DISEASE
. Shewas given nitroglycerin gtt diltiazem 10mg IV x2 aspirinlevofloxacin and furosemide 20mg IV x1. Per documents shereceived 2L IVF. She was temporarily started on BIPAP howeverdid not tolerate well with
hypotension
DISEASE
and
tachycardia
DISEASE
. This wasdiscontinued and patient has been stable with vitals at transferof HR 105 BP 129/66 RR 26 SaO2 100% NRB..Currently no distress although neglects left side. No movementof left side. No
respiratory distress
DISEASE
..ROS: Unable to obtain.Past Medical History:-
Atrial fibrillation/flutter
DISEASE
-
Schizophrenia
DISEASE
-
Anemia
DISEASE
- h/o
syncope
DISEASE
-
Dementia
DISEASE
-
Cardiomyopathy
DISEASE
- Paroxysmal
ventricular tachycardia
DISEASE
- h/o C. Diff
colitis
DISEASE
- h/o
peptic ulcer disease
DISEASE
- PPD positive- h/o
cellulitis
DISEASE
Social History:Reportedly non-verbal although can communicate when in
pain
DISEASE
.Lives at [**First Name8 (NamePattern2) 1116**] [**Last Name (NamePattern1) **] Nursing Home. Normally can say name andwalks with shuffling gait. No known history of smoking.Family History:Unable to obtain.Physical Exam:ADMISSION
EXAM
DISEASE
:VS: T: 96.2 Ax BP: 171/81 HR: 123 RR: 24 O2sat: 99% NRB 15LGEN: non-verbal no apparent distress some
wasting
DISEASE
HEENT: PERRL eyes deviated to right dry MM op without lesionsalthough limited viewNeck: no supraclavicular or cervical lymphadenopathyapprecaited Admission Date: [**2114-5-11**] Discharge Date: [**2114-5-23**]Date of Birth: [**2054-1-30**] Sex: FService: SURGERY
Allergies
DISEASE
:Ace InhibitorsAttending:[**First Name3 (LF) 158**]Chief Complaint:Abd
pain
DISEASE
and
N/V
DISEASE
Major Surgical or Invasive Procedure:s/p right and left hemicolectomyHistory of Present Illness:60F with
ESRD
DISEASE
s/p deceased donor renal transplant
HTN
DISEASE
and
diverticulitis
DISEASE
who was initially admitted for worsening
abdominal pain
DISEASE
and
N/V
DISEASE
and now presents to the [**Hospital Unit Name 153**] with
hypotension
DISEASE
after having a n ex-lap and bowel resection for aperforated cecum. She has had approximately 3 episodes of
diverticulitis
DISEASE
in the past year which resolved with antibiotics. She was planning to have an elective outpatient laparoscopiccolectomy given her frequent
flares
DISEASE
. Prior to this admissionshe reportedly had intermittent [**10-3**]
abdominal pain
DISEASE
in the RLQand LLQ and significant
nausea
DISEASE
and
vomiting
DISEASE
she was unable tokeep down any POs for 48 hours prior to admission. This feltworse than her prior
diverticulitis flares
DISEASE
and she was admittedfor observation hydration and antibiotics. CT abd/pelvis atadmission showed pericolonic stranding but no e/o
diverticulitis
DISEASE
.Since admission to the surgery service she was staretd on Ciproand Flagyl for the
colitis
DISEASE
seen on CT. Her
abdominal pain
DISEASE
acutely worsened on [**5-12**] and she described feeling a Admission Date: [**2131-10-16**] Discharge Date: [**2131-10-22**]Date of Birth: [**2057-1-5**] Sex: MService: NeurosurgeryHISTORY OF PRESENT ILLNESS: MR. [**Known lastname 1127**] is a 74 year old righthanded white male who presented to the Emergency Room with
headache
DISEASE
and difficulty speaking. He has a history of leftoccipital arteriovenous malformation which was resected in[**2131-4-10**] by Dr. [**Last Name (STitle) 1128**] at [**Hospital6 1129**] and[**2130-12-11**]. He had residual right visual field deficitrelated to his last bleed and surgery.Yesterday in the late morning the patient began having asevere constant
headache
DISEASE
in the left occipital region andassociated increased in the size of his right visual fielddefect and difficulty speaking. He denied any focalREVIEW OF SYSTEMS: The patient denied
fever chills nausea
DISEASE
vomiting
DISEASE
or change in appetite. He has lost ten pounds overthe last ten months. He has no
chest pain palpitations
DISEASE
or
shortness of breath no abdominal pain
DISEASE
no change in bowel orbladder habits.PAST MEDICAL HISTORY: 1. Left occipital arteriovenous
malformation
DISEASE
resected in [**2131-4-10**] at [**Hospital6 1130**] by Dr. [**Last Name (STitle) 1128**] on
seizure
DISEASE
prophylaxis. 2.Tonsillectomy.ALLERGIES: The patient has no known drug
allergies
DISEASE
.MEDICATIONS ON ADMISSION: Trileptal 300 mg p.o.b.i.d. andstool softener.SOCIAL HISTORY: The patient is a retired sculptor. He ismarried with one son and lives with his wife. [**Name (NI) **] has had norecent alcohol use no tobacco or drug use.PHYSICAL EXAMINATION: On physical examination the patienthad a blood pressure of 173/83 heart rate 74 and oxygensaturation 100%. General: Patient appeared stated agelying in bed. Head eyes ears nose and throat: Sclerae
white oropharynx clear
DISEASE
without lesions pupils equal roundand reactive to light. Neck: Supple no jugular venousdistention no
bruits
DISEASE
no
tenderness
DISEASE
. Lungs: Clear toauscultation bilaterally. Cardiovascular: Regular rate andrhythm normal S1 and S2 no murmur. Abdomen: Softnontender nondistended positive bowel sounds. Extremities:Warm no
cyanosis clubbing
DISEASE
or
edema
DISEASE
peripheral pulses allfelt.Neurologic examination: Awake alert and cooperative couldnot name days of week forward and backward could not namecommon or uncommon objects could point to objects when askedbut not letters or shapes calculation was deficient forsimple math could repeat numbers but not sentences couldnot read or copy tests stereognosia and graphesthesiapresent in right hand more than left. Speech: Couldinitiate spontaneous speech with normal patterns andpronunciation initially but had word finding difficultiesAdmission Date: [**2195-11-23**] Discharge Date: [**2195-12-2**]Date of Birth: [**2127-7-17**] Sex: MService: MEDICINE
Allergies
DISEASE
:Ivp Dye Iodine Containing / AtivanAttending:[**Last Name (NamePattern1) 1136**]Chief Complaint:
hypoglycemia
DISEASE
Major Surgical or Invasive Procedure:Incision and drainage with resection of first metatarsal[**2195-11-25**]Wound closure [**2195-11-30**]History of Present Illness:Mr. [**Known lastname 1137**] is a 68yo M w/hx of
DM2
DISEASE
(A1c [**10-23**] 7.1%) afib oncoumadin chronic
diabetic foot ulcers
DISEASE
h/o EtOH abuse and
HTN
DISEASE
who was sent in from his PCPs office with symptomatic
hypoglycemia
DISEASE
to 36 that has been ongoing for 3Admission Date: [**2108-2-17**] Discharge Date: [**2108-2-22**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1145**]Chief Complaint:SOBMajor Surgical or Invasive Procedure:cardioversionHistory of Present Illness:83 y/o F with h/o MI s/p 4 vessel CABG
CHF
DISEASE
mitralregurgitation with worsening SOB and DOE over the last fewmonths. Pt reports that she is now able to walk much less thana block without feeling short of breath and that this hasgotten worse in the last few months. However she denies anacute worsening of shortness of breath/DOE prior to heradmission. Shortness of breath has not been associated with
wheezing
DISEASE
. No associated
chest pain
DISEASE
. Pt notes paroxysmal
nocturnal dyspnea
DISEASE
about 2-3 episodes per night every night.
Denies orthopnea
DISEASE
and notes no changes in the number of pillowsused.
Denies fevers cough rhinorrhea chest pain diarrhea
DISEASE
or
dysuria
DISEASE
. Denies lower extremity edema.
Denies palpitations
DISEASE
.Reports that she has been taking her medications without missingdoses or running out of medicine. Denies any change in herdietAdmission Date: [**2163-7-5**] Discharge Date: [**2163-7-15**]Date of Birth: [**2097-6-11**] Sex: FService: MEDICINE
Allergies
DISEASE
:Bactrim / Ciprofloxacin / CodeineAttending:[**First Name3 (LF) 1162**]Chief Complaint:AMSMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:66 yo F with h/o
PE renal failure
DISEASE
last Cr 5
seizure
DISEASE
d/o wasfound down apparently x9 days after an unwitnessed
seizure
DISEASE
. Ptmanaged to crawl to window yell for help EMS arrived whichtook pt to OSH. Pt has been recently hospitalized for malaise[**Date range (1) 1163**]/[**2163**] and found to be in
renal failure
DISEASE
which wasthought to be
pre-renal
DISEASE
in the setting of poor PO intake
hypotension
DISEASE
from
adrenal insufficiency
DISEASE
while off steriods. HerCr improved from 5.6 to 1.3 with IVF. She was also discharged oncefuroxime for a
UTI
DISEASE
abx to be completed [**6-24**]. Pt wasdischarged to extended care facility on [**6-17**]..OSH: Arrived via EMS
speech slurred
DISEASE
found pt in filthy apptdried feces on legs cat feces and urine feces everywhere.Initial VS 96.1 BP 84/50 HR 103 86%RA FS 73. Initial BUN/Cr110/10.1 K 4.4 Alb 2.7 WBC 19.7 HCT 33.2 PLT 444 5%BandsINR 2.1. Tox screen Admission Date: [**2191-4-24**] Discharge Date: [**2191-4-27**]Service: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**Last Name (NamePattern1) 1167**]Chief Complaint:
Dyspnea
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:[**Age over 90 **]F with
HTN Dyslipidemia
DISEASE
and Admission to [**Hospital1 882**] in [**2190-8-23**]for
acute pulmonary edema
DISEASE
presents from [**Hospital **] rehab c/o sob.Pt lasix was noted to have been discontinued on end of [**3-16**]to the fact that she had no
peripheral edema
DISEASE
. Around 1am shewas found to be short of breath and O2 sat of 82% on Room airand diaphoretic. Other vital signs were 98.4 107 136/74. Shewas placed on 2L NC given albuterol and lasix 20mg PO. Her O2sats increased to 88% and she put out 300cc of urine while enroute to [**Hospital1 18**] ED..In the ED T:99.8 HR: 108 BP 147/87 RR: 32 91%NRB. Pt wasunable to speak in full sentences and T wave inversions in V4-6trop 0.18 and proBNP: [**Numeric Identifier 1168**]. Placed on BIPAP and givenkayexalate 30mg PO for K of 6.0 aspirin 325mg PO x1 and lasix20mg IV x1. Vancomycin 1gm an cefepime 2gm Nitro gtt started.Pt diuresed 350cc of lasix in the ED. No effusion on bedside(ED) echo. CXR showed
vascular congestion
DISEASE
and bilateral pleuraleffusions. Most Recent VS: 96 164/84 23 96%
NRB
DISEASE
.On review of systems She denies recent
fevers chills
DISEASE
orrigors. She denies
exertional buttock
DISEASE
or
calf pain
DISEASE
.
Denies
DISEASE
chest
pain nausea vomiting diarrhea
DISEASE
change in urnary habits URIsymptoms. All of the other review of systems were negative..Positive for
cough
DISEASE
for last month. Non-productive similarduring the day as well as at night could not tell us ifanything makes it better or worse..Cardiac review of systems is notable for absence of
chest pain
DISEASE
dyspnea
DISEASE
on
exertion paroxysmal nocturnal dyspnea orthopnea
DISEASE
ankle
edema palpitations syncope
DISEASE
or
presyncope
DISEASE
.Past Medical History:1. CARDIAC RISK FACTORS: -
Diabetes
DISEASE
Admission Date: [**2139-10-23**] Discharge Date: [**2139-10-31**]Date of Birth: [**2063-1-13**] Sex: MService: TRANS [**Doctor First Name 147**]HISTORY OF PRESENT ILLNESS: This is a 76 year old man who isstatus post a right upper extremity
AV fistula
DISEASE
three daysprior to admission who now presents with right upperextremity swelling. This
swelling
DISEASE
is associated withsignificant
pain
DISEASE
of his right arm and the patient does reportthat prior to the surgery his arms were of similar caliber.He denies
fevers
DISEASE
or
chills shortness of breath or abdominal
DISEASE
pain
DISEASE
.PAST MEDICAL HISTORY:1.
Diabetes mellitus
DISEASE
.2. Peripheral
vascular disease
DISEASE
.3. End-stage
renal disease
DISEASE
on hemodialysis.4. Congestive
heart failure
DISEASE
.5. Coronary
artery disease
DISEASE
.6. Pulmonary
hypertension
DISEASE
.7. Benign
prostatic hypertrophy
DISEASE
.8. Sleep apnea.PAST SURGICAL HISTORY:1. Right radius
cephalic AV fistula
DISEASE
in 06/[**2137**].2. Right lobectomy for benign
lung tumor
DISEASE
in [**2085**].3. Revision of the right upper extremity AV fistula threedays prior to admission.MEDICATIONS AT HOME:1. Enteric coated aspirin 325.2. Lipitor 40 mg once a day.3. Colace 100 mg twice a day.4. Nephrocaps one tablet once a day.5. Lopressor.6. Magnesium 125 mg once a day.7. Imdur 60 mg once a day.8. CPAP.9. Insulin Humulin 70/30 33 units with breakfast and 14units with dinner.PHYSICAL EXAMINATION: Vital signs were temperature of 99.7F.Admission Date: [**2195-4-14**] Discharge Date: [**2195-4-17**]Date of Birth: [**2123-12-24**] Sex: FService: MEDICINE
Allergies
DISEASE
:Atorvastatin / Penicillins / Codeine / OxycodoneAttending:[**First Name3 (LF) 2290**]Chief Complaint:Left leg swelling/edemaMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:71F with history of
CHF
DISEASE
CAD afib on coumadin ESRD on
HD
DISEASE
and
COPD
DISEASE
presenting with
pain swelling
DISEASE
and
erythema
DISEASE
on the leftleg. Patient has had chronic
ulcers
DISEASE
of the left and right legsince last [**Month (only) 216**] and had been on vancomycin for 2 week coursecompleted on [**2195-2-19**]. Today noted increased
swelling
DISEASE
and
pain
DISEASE
in the left calf which had changed from previous baseline asshe had not had
pain
DISEASE
in the leg before No f/c. No n/v/d. NoCP/SOB. The
blisters
DISEASE
on her legs occasionally drain nonpurulent fluid but she reports no increased drainage over thepast few days. Was given a dose of vancomycin at HD..In the ED initial VS were: 8 98 64 131/113 16 99%. Patient wasnot given any additional antibiotics given recent dose at HD.Underwent LLE ultrasound which showed no evidence of
DVT
DISEASE
butsubstantial subcutaneous
edema
DISEASE
. Patient was to be admitted tofloor but repeat vitals showed BP of 80/50. Patient wasasymptomatic at that time without CP/SOB lightheadedness orvisual changes. Was given a 500cc bolus and responded to 89/50.Subsequently admitted to MICU for further monitoring of vitalsigns..On arrival to the MICU patient is alert and oriented in NAD.Notes minimal
pain
DISEASE
and
swelling
DISEASE
in the left calf. Denies f/c.Denies CP/SOB. Of note she reports multiple week history of
cough
DISEASE
for which she was started on doxycycline by her PCP [**Last Name (NamePattern4) **][**4-10**]. Otherwise has no other complaints.Past Medical History:-
Hypertension
DISEASE
- Hyperlpidemia-
Ventricular tachycardia
DISEASE
s/p ICD implantation [**2193-4-1**] ([**Company 2275**] Cognis 100-D Dual chamber-ICD)-
Heart failure
DISEASE
systolic and diastolic EF 35%-
Atrial fibrillation
DISEASE
on warfarin- Coronary artery disease-
COPD
DISEASE
-
Psoriasis
DISEASE
-
Gout
DISEASE
-
Allergic rhinitis
DISEASE
-
Hypokalemia
DISEASE
(in past)-
Anemia
DISEASE
normocytic-
ESRD
DISEASE
- Obesity-
Cataract
DISEASE
- Colon polyps- Diverticulosis of colon with
hemorrhage
DISEASE
Social History:-Former tobacco [**12-1**] pack per day x 25 years-Previous alcohol use: quit 2 years ago-Denies recreational drug use or other toxic habits-Lives alone. Is able to complete her ADLs.Family History: [**Name (NI) 2280**] mother with 'heart trouble'Physical Exam:Vitals: T: 97.6 BP: 91/57 P: 65 R: 26 O2: 98%General: Alert oriented no acute distressHEENT: MMM oropharynx clear EOMI PERRLNeck: supple JVP not elevated no LADCV: Regular rate and rhythm normal S1 Admission Date: [**2154-12-14**]
Death
DISEASE
Date: [**2154-12-15**]Service: MEDICINE/[**Doctor Last Name 1181**]HISTORY OF PRESENT ILLNESS: The patient is a 78-year-oldmale with a history of
encephalitis oral cancer
DISEASE
presentingto Intensive Care Unit with
shortness of breath
DISEASE
and
hypoxia
DISEASE
secondary to a large
pleural effusion
DISEASE
. While in theIntensive Care Unit the patient had transient
hypotension
DISEASE
and had a large O2 requirement secondary to the large effusionand multiple pulmonary nodules almost certainly representingmetastatic disease. The patient was stabilized with IVF andsupplemental O2. The medical situation including presumedwidely metastatic
cancer
DISEASE
with likely
malignant effusion
DISEASE
wasdiscussed with the patient. Mr. [**Known lastname 1182**] firmly delined furtherdiagnostic interventions or therapies to work up and treat this.Based on his firmly expressed opinion his code statuswas made DNR/DNI and primary driver changed to maintainingcomfort.On [**2154-12-15**] the patient was stable for transfer to floor forfurther care. He remained with a high supplemental FiO2requirement in order to maintain borderline sats. Mr. [**Known lastname 1182**]frequently removed his face mask saying that he just wanted tobe comfortable. He expressed understanding that going withoutsupplemental Oxygen would put him at risk for respiratory or
cardiac arrest
DISEASE
.On [**2154-12-15**] at 11:05 pm the senior resident was called tosee patient for unresponsiveness. The patient had continuedto refuse oxygen during the day into the evening. He had onlyintermittently complied with wearing the mask secondary tocomfort concerns. as he had done in the MICU and earlin theOn evaluation by the sernior resident the patient had norespirations. The patient had no response to voice orsternal rub or other painful stimuli. The patient had noheart sounds. Pupils were fixed and dilated. The patient waspronounced dead. The Attending was notified and familycontact[**Name (NI) **]. DR.[**Last Name (STitle) **][**First Name3 (LF) **] 12-948Dictated By:[**Last Name (NamePattern1) 1183**]MEDQUIST36D: [**2155-2-12**] 10:54T: [**2155-2-12**] 11:12JOB#: [**Job Number 1184**]Admission Date: [**2136-12-19**] Discharge Date: [**2136-12-23**]Date of Birth: [**2058-12-17**] Sex: FService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 1185**]Chief Complaint:
Confusion lethargy
DISEASE
and
hyperglycemia
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:78F h/o
Atrial fibrillation
DISEASE
(not on coumadin)
dementia
DISEASE
and
DM2
DISEASE
sent in from rehab for altered MS today. She is demented atbaseline AAOx person and place and able to report immediatemedical complaints. She is a poor historian and oriented onlyto self. She is stating only that she does not feel well.Denies specific complaints when asked including
chest pain
DISEASE
SOB
cough abdominal pain N/V diarrhea
DISEASE
and
dysuria
DISEASE
. Did notanswer question about sick contacts. Daughter thinks she maynot have been eating quite as well as usual but otherwise hasbeen in her usual state of health without any complaints..In the ED initial vitals 97.8 91 100/60 16 98%
RA
DISEASE
. Labssignificant for glucose 1053 Hct 54 AG 25 Creatinine 1.7lactate 8.1 K 4.0 Na 141 trop Admission Date: [**2184-10-10**] Discharge Date: [**2184-10-16**]Date of Birth: [**2134-3-31**] Sex: MService: MED
Allergies
DISEASE
:Penicillins / Nsaids / CiprofloxacinAttending:[**First Name3 (LF) 1190**]Chief Complaint:
Rash
DISEASE
Major Surgical or Invasive Procedure:None.History of Present Illness:50 yo male with PMH significant for EtOH abuse as well asseveral psychological diagnoses presents to ER for evaluationof
rash
DISEASE
on his chest and legs/groin 1 week after startingciproflox for R hand
cellulitis
DISEASE
.
Rash
DISEASE
is
pruritic
DISEASE
. No associated
fever
DISEASE
no respiratory compromise. In ER noted to be quite
tremulous
DISEASE
. Stated last drink was within 24h has a history ofAdmission Date: [**2158-9-14**] Discharge Date:Date of Birth: [**2115-11-19**] Sex: MService: [**Company 191**] MEDHISTORY OF PRESENT ILLNESS: This is a 42 year old Caucasianmale with a history of [**Location (un) 849**]-Gastaut syndrome refractory
epilepsy mental retardation
DISEASE
and frequent urinary tract
infections
DISEASE
who now presents with a two day history ofincreased
seizure
DISEASE
activity increased
lethargy
DISEASE
and decreasedp.o. intake. This history is obtained from the patient'scaregiver. [**Name (NI) **] himself is nonverbal. Apparently patienthas an average of six
seizures
DISEASE
per month
tonic clonic
DISEASE
innature and associated with a 30 minute post ictal state. Inthe past two days he has had a total of six
seizures
DISEASE
already.He is refusing all p.o. intake including his medications forthe past two days. The caregiver reports that his
seizures
DISEASE
usually increase in frequency when there is an associated
infection
DISEASE
. He did have one episode of
nausea
DISEASE
withquestionable coffee ground
emesis
DISEASE
one day prior to admission.He was sent home from [**Hospital3 1196**] emergencydepartment after negative lavage and hematocrit of 40 one dayprior to admission. There is no evidence of sick contacts
fever
DISEASE
at home
chills cough shortness
DISEASE
of breath chest
pain pain
DISEASE
anywhere
foul smelling urine urinary
DISEASE
frequency
head injury rhinorrhea photophobia
DISEASE
.PAST MEDICAL HISTORY: [**Location (un) 849**]-Gastaut syndrome diagnosed atage 10 associated with approximately six
seizures
DISEASE
a month.Refractory
epilepsy
DISEASE
. Partial synostosis of the left lambdoidsuture with
compression of the left occipital lobe
DISEASE
andposterior parietal lobe.
Gastroesophageal reflux disease
DISEASE
.Mental retardation. Recurrent
urinary tract infections
DISEASE
.
Sinusitis
DISEASE
. Microcephaly.MEDICATIONS ON ADMISSION: Colace 100 b.i.d. Protonix 40q.d. Trileptal 600 t.i.d. Zoloft 100 q.d. Tums 1500 q.d.multivitamin Felbatol 800 b.i.d. Miacalcin nasal spray.ALLERGIES: Depakote (
rash
DISEASE
) Neurontin (
rash
DISEASE
) phenobarbitalZarontin.FAMILY HISTORY: Unknown. The caregiver does state thatpatient's mother lives in the [**Name (NI) 86**] area.SOCIAL HISTORY: The patient lives in a group home since [**2137**]with five other mentally disabled people. He requiresconstant supervision. He is nonverbal at baseline but isable to communicate his needs per caregiver. There is nohistory of tobacco alcohol or recreational drug use.PHYSICAL EXAMINATION: Temperature 100.3 blood pressure130/42 pulse 100 respirations 20 sating 86% in room air.In general this was a pale
cachectic
DISEASE
Caucasian male whoappeared younger than his stated age. He was awake did notmake any eye contact and was extremely agitated and
restless
DISEASE
requiring soft restraints. Pupils were equally round andreactive to light. Nares were patent. Oropharynx was clearbut with poor dentition. Mucous membranes were moist. Neckwas supple without
lymphadenopathy
DISEASE
JVD or
carotid bruits
DISEASE
.Lungs revealed coarse breath sounds anteriorly bilaterally.Cardiac exam revealed that he was slightly tachycardiac S1S2 normal without appreciable murmurs gallops or rubs.Abdomen was soft nondistended nontender with normal bowelsounds and no masses. Extremities displayed multiple areasof
ecchymosis
DISEASE
on his left lower extremity but were otherwiseunremarkable without evidence of
edema erythema
DISEASE
or unusualrashes. Neurologically patient moved all four extremitiesspontaneously. He was nonverbal and did not follow commands.There were no deep tendon reflexes elicited. Toes wereupgoing bilaterally but there were no signs of clonus.LABORATORY DATA: Labs on admission notable for white countof 18.7 with diff of 90 neutrophils 1 band 3 lymphocytes 6monos. Hematocrit was 39 MCV 91. Sodium was 130 BUN 19creatinine 0.7. UA demonstrated specific gravity of 1.020with pH of 8 and all else negative. Chest x-ray on admissionwas within normal limits and negative for any signs of
pneumonia
DISEASE
.HOSPITAL COURSE: Given the patient's
leukocytosis
DISEASE
and lowgrade temperature both blood and urine cultures were drawn.These continued to remain negative throughout his hospitalstay. Repeat chest x-ray was performed on hospital day oneand demonstrated left lower lobe atelectasis versusinfiltrate. Patient was thus started on empiric IV Levaquinon hospital day one. He was aggressively hydrated with IVfluids initially with normal saline secondary to sodium of130. When his sodium normalized he was switched tomaintenance IV fluids. He was placed on both aspiration andfall precautions and supervised by a one-to-one sitter at alltimes. Given his questionable history of upper GI bleed oneday prior to admission hematocrit was followed closely andremained stable throughout his hospital stay. He wascontinued on daily Protonix and his stools were guaiac'd allof which remained negative.Regarding his
seizure disorder
DISEASE
patient was continued on hisoutpatient antiepileptics including Trileptal and Felbatol.Since our pharmacy did not carry Felbatol he was allowed totake his medications from home. He was placed in softrestraints for his own safety during his
seizure
DISEASE
episodes.His outpatient neurologist Dr. [**Last Name (STitle) 851**] was informedof the patient's in-house status. He was also given 0.5 mgof p.r. or IV Ativan for prolonged
seizures
DISEASE
. As his
infection
DISEASE
and
dehydration
DISEASE
were both treated patient's
seizures
DISEASE
decreased in frequency and he soon returned to hisbaseline status.DISCHARGE DIAGNOSES:1. Pneumonia aspiration versus community acquired.2. Dehydration.3. Refractory
epilepsy
DISEASE
secondary to [**Location (un) 849**]-Gastaut syndrome.4.
Hypokalemia
DISEASE
.5.
Hypomagnesemia
DISEASE
.DISCHARGE MEDICATIONS:1. Colace 100 b.i.d.2. Protonix 40 q.d.3. Trileptal 600 t.i.d.4. Zoloft 100 q.d.5. Multivitamin.6. Felbatol 800 b.i.d.7. Miacalcin nasal spray.8. Levaquin 500 q.d. for a total of a seven day course.DISCHARGE STATUS: The patient was discharged back to hisgroup home from where he came in good condition. He is tocontinue all his preadmission medications including a sevenday course of p.o. Levaquin for his presumed
pneumonia
DISEASE
. Heis to follow up with his outpatient neurologist within thenext two weeks. [**Name6 (MD) 251**] [**Name8 (MD) **] M.D. [**MD Number(1) 1197**]Dictated By:[**Last Name (NamePattern4) 1198**]MEDQUIST36D: [**2158-9-15**] 19:50T: [**2158-9-15**] 20:20JOB#: [**Job Number 1199**]Admission Date: [**2158-9-14**] Discharge Date: [**2158-9-21**]Date of Birth: [**2115-11-19**] Sex: MService: [**Company 191**] MedicineStat addendum:Unfortunately the patient was not discharged on [**9-16**]as expected. On the morning of [**9-17**] he went into
status epilepticus
DISEASE
secondary to missing his scheduled dosesof his oral anti-epileptics. He was immediately intubatedfor adequate airway protection and transferred to theIntensive Care Unit for a brief stay. In the Intensive CareUnit he was started on an Ativan drip to break his
seizures
DISEASE
and was loaded with Dilantin. His antibiotics were alsochanged to intravenous clindamycin and ceftriaxone for apresumed aspiration
pneumonia
DISEASE
. A head CT was obtained whichwas negative for any
hemorrhage
DISEASE
or acute changes from hisprior study.The patient was extubated without any complications after a24 hour stay in the Intensive Care Unit. The EEG wasobtained prior to extubation which confirmed severe
encephalopathy
DISEASE
but no further
seizure
DISEASE
activity. The patientwas then transferred to the floor on [**9-18**] in stablecondition. His Ativan drip his OT tube and his central linewere all discontinued. His IV Dilantin was then changed topo Dilantin and was increased by the neurology service.Daily Dilantin levels were checked. He continued to remainafebrile with all vitals stable throughout the rest of hishospital stay. He remained
seizure
DISEASE
free and was able totolerate po's (both medications and food) without anytrouble. His intravenous antibiotics were changed to a poregimen on the day of discharge.DISCHARGE STATUS: He will be discharged back to his grouphome on [**9-18**] in good condition. He is to resume allpre admission medications with the addition of po Dilantin125 mg in the morning 100 at noon and 100 at night. He isalso to complete a seven day course of po Levaquin. He is tofollow up with Dr. [**Last Name (STitle) 851**] his neurologist within thenext two weeks. [**Name6 (MD) 251**] [**Name8 (MD) **] M.D. [**MD Number(1) 1197**]Dictated By:[**Last Name (NamePattern4) 1198**]MEDQUIST36D: [**2158-9-21**] 10:23T: [**2158-9-21**] 10:46JOB#: [**Job Number 1200**]Admission Date: [**2164-5-4**] Discharge Date: [**2164-5-18**]Date of Birth: [**2115-11-19**] Sex: MService: SURGERY
Allergies
DISEASE
:Phenobarbital / Depakote / Zarontin / Gabapentin / Zonegran /Tranxene SdAttending:[**First Name3 (LF) 148**]Chief Complaint:
Abdominal Pain
DISEASE
Major Surgical or Invasive Procedure:1. Exploratory laparotomy.2. Exploration of retroperitoneum.3. Open cholecystectomy.4. Venting decompressed colotomy.5. J-tube placement.History of Present Illness:This 48-year-old [**First Name3 (LF) 1229**] has mental retardation and a
seizure
DISEASE
syndrome. He presents to our emergency room acutely with reportsof [**1-15**] days of abdominal
pain
DISEASE
as described by his caretakers who find him
grimacing
DISEASE
inan umbilical position. He had a change in bowel habits anddecreased PO intake for 2 weeks. He is largely unresponsive andhe responds only to keep the stimulation for
pain
DISEASE
. He has had
fevers
DISEASE
for the last few days up as high as 104 degrees. Aworkup was performed for this and initial imaging of theabdomen showed multiple views consistent with a free air in theabdomen. This with a lactic
acidosis
DISEASE
distended abdomen and a
neutrophilia
DISEASE
band shift along with the after mentioned historywas very concerning for an acute process whichrequired an emergent operation. This was especially so given thefact that we could not adequately communicate with this[**Name2 (NI) 1229**] and did not know the full extent of his recognition of
pain
DISEASE
due to his mental retardation.Past Medical History:[**Location (un) 849**]
Gastaut
DISEASE
Syndrome neurologist Dr. [**Last Name (STitle) 851**]
Seizure disorder
DISEASE
Mental retardation
Osteoporosis
DISEASE
Peripheral neuropathy
DISEASE
secondary to dilantinh/o
hyponatremia
DISEASE
secondary to trileptalGERDBehavioral d/oSocial History:Lives in group home. Non-verbal at baseline. Does not smoke ordrink EtOH.Patient lives in a group home. # [**Telephone/Fax (1) 852**]. Has a legalguardian Rev [**First Name8 (NamePattern2) **] [**Name (NI) 853**] c # [**Telephone/Fax (1) 854**] w # [**Telephone/Fax (1) 855**].Family History:NoncontributoryPhysical Exam:104 100 94/37Gen: non responsive NAD no
jaundice
DISEASE
CV: S1 S2 no MRGChest: CTA bilat decreased at right baseAbd: soft nondistended no rebound or guarding.Pertinent Results:[**2164-5-4**] 07:05PM BLOOD WBC-10.0# RBC-4.49* Hgb-12.9* Hct-39.8*MCV-89 MCH-28.8 MCHC-32.5 RDW-16.9* Plt Ct-296[**2164-5-8**] 01:58AM BLOOD WBC-14.2* RBC-3.29* Hgb-9.7* Hct-29.3*MCV-89 MCH-29.5 MCHC-33.1 RDW-17.0* Plt Ct-232[**2164-5-8**] 09:40AM BLOOD Glucose-114* UreaN-8 Creat-0.5 Na-131*K-3.6 Cl-95* HCO3-25 AnGap-15[**2164-5-6**] 02:08AM BLOOD ALT-83* AST-125* LD(LDH)-222 AlkPhos-62Amylase-19 TotBili-0.3[**2164-5-8**] 09:40AM BLOOD Calcium-7.3* Phos-3.3# Mg-1.4*[**2164-5-4**] 11:57PM BLOOD Triglyc-78[**2164-5-8**] 01:58AM BLOOD Phenyto-17.1.CHEST (PORTABLE AP) [**2164-5-4**] 7:25 PMPORTABLE UPRIGHT CHEST ONE VIEW: Heart size is normal. There isa mild hilar prominence with patchy areas of airspace
opacities
DISEASE
bilaterally. Given the history of prolonged
seizure
DISEASE
these mayrepresent areas of aspiration. There is no
pneumothorax
DISEASE
. Thereis no
pleural effusion
DISEASE
.There is a massive amount of free intraperitoneal air with freeair seen underneath both hemidiaphragms. Osseous structures areunremarkable.IMPRESSION:1. Massive amount of pneumoperitoneum.2. Multifocal patchy areas of airspace
opacity
DISEASE
likelyrepresents aspiration and possible superimposed neurogenic
pulmonary edema
DISEASE
..CHEST (PORTABLE AP) [**2164-5-5**] 4:07 PMComparison is made with prior study performed the same dayearlier in the morning.Cardiomediastinal contour is unchanged. Diffuse airspace
opacities
DISEASE
worse on the right side are unchanged. There are nonew
lung abnormalities
DISEASE
. As mentioned before these aresuspicious for aspiration. There are no increasing pleuraleffusions..CHEST (PORTABLE AP) [**2164-5-8**] 8:07 AMFINDINGS: In comparison with the study of [**5-5**] there has beensome decrease in the still substantial bilateral pulmonaryopacifications suspicious for aspiration..CHEST (PORTABLE AP) [**2164-5-9**] 1:14 AMCHEST (PORTABLE AP)Reason: new NGT[**Hospital 93**] MEDICAL CONDITION:48 year old man s/p ccyREASON FOR THIS EXAMINATION:new NGTHISTORY: New nasogastric tube.FINDINGS: In comparison with the study of [**5-8**] there has beenplacement of a nasogastric tube that coils within the fundus ofthe stomach. The diffuse bilateral
pulmonary opacification
DISEASE
showsa slow steady decrease..[**2164-5-15**] 06:00AM BLOOD WBC-13.1* RBC-3.44* Hgb-10.3* Hct-31.3*MCV-91 MCH-29.9 MCHC-32.9 RDW-18.3* Plt Ct-940*[**2164-5-18**] 09:25AM BLOOD WBC-16.0* RBC-2.91* Hgb-8.7* Hct-26.9*MCV-93 MCH-29.8 MCHC-32.2 RDW-18.7* Plt Ct-960*[**2164-5-14**] 05:55AM BLOOD Glucose-86 UreaN-6 Creat-0.5 Na-132*K-4.0 Cl-101 HCO3-22 AnGap-13[**2164-5-6**] 02:08AM BLOOD ALT-83* AST-125* LD(LDH)-222 AlkPhos-62Amylase-19 TotBili-0.3[**2164-5-18**] 09:25AM BLOOD Albumin-2.5*[**2164-5-14**] 05:55AM BLOOD Calcium-7.4* Phos-3.1 Mg-2.1[**2164-5-16**] 06:05AM BLOOD Vanco-20.5*[**2164-5-13**] 12:25PM BLOOD Vanco-11.9[**2164-5-18**] 04:54AM BLOOD Phenyto-7.2*[**2164-5-16**] 06:10AM BLOOD Phenyto-13.7[**2164-5-15**] 06:00AM BLOOD Phenyto-8.5*[**2164-5-14**] 05:55AM BLOOD Phenyto-5.4*[**2164-5-12**] 06:05AM BLOOD Phenyto-10.4.ECHOConclusionsThe left atrium is normal in size. Left ventricular wallthickness cavity size and regional/global systolic function arenormal (LVEF Admission Date: [**2194-2-16**] Discharge Date: [**2194-2-19**]Date of Birth: [**2130-11-19**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1242**]Chief Complaint:
Hyperglycemia
DISEASE
unsteady gaitMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:63 yof with history of of DM Type I CAD s/p MI s/p CABG
HTN
DISEASE
Hyperlipidemia PVD
DISEASE
s/p left popliteal bypass who presents with
hyperglycemia
DISEASE
. Pt was recently discharged after admission for
hyperglycemia
DISEASE
and
TIA
DISEASE
. Patient states she was home and notfeeling herself. Admission Date: [**2166-3-17**] Discharge Date: [**2166-3-24**]Date of Birth: [**2126-8-18**] Sex: MService: MEDICINE
Allergies
DISEASE
:Penicillins / Kefzol / Ibuprofen / Ketoconazole / Adhesive Tape/ Shellfish DerivedAttending:[**First Name3 (LF) 1257**]Chief Complaint:etoH withdrawalMajor Surgical or Invasive Procedure:R femoral lineHistory of Present Illness:Pt is a 39 yo M c h/o EtOH abuse recurrent
abdominal pain
DISEASE
gastritis
DISEASE
Admission Date: [**2168-5-6**] Discharge Date: [**2168-5-11**]Date of Birth: [**2126-8-18**] Sex: MService: MEDICINE
Allergies
DISEASE
:Penicillins / Kefzol / Ibuprofen / Ketoconazole / adhesive tape/ Shellfish DerivedAttending:[**First Name3 (LF) 1115**]Chief Complaint:EtOH withdrawal sxsMajor Surgical or Invasive Procedure:None.History of Present Illness:41 y.o. Male with current EtoH abuse h.o. DTs
seizures
DISEASE
presents EtoH withdrawal symptoms..Pt states he usually drinks at least a 12 pack a dayunfortunately he could not afford any more alcohol so he startedto withdraw. His last drink was yesterday at 5pm. He noted some
sweats diarrhea chills
DISEASE
and a
headache
DISEASE
along with
tremors
DISEASE
whichhe usually experiences when he withdraws. He also noted some
epigastric pain
DISEASE
with radiation to the back after he stoppeddrinking he started to eat something this morning and threw itup. He threw it up because of his
abdominal pain
DISEASE
and
nausea
DISEASE
. Hesaid the 3 rd time he threw up he noted some blood whichincreased in concentration the more he threw up. He decided tocome into the ED for his withdrawal and
pain
DISEASE
issues..In the ED initial VS were noted to be T98.8 HR 116 BP 199/108RR 18 Sat 100% on
RA
DISEASE
. Her initial labwork was notable for anegative serum tox screen including EtoH. He was noted to havetongue fasiculations
tremors
DISEASE
and was given initially Diazepam10mg IV x 1 10mg PO x 1. He was also noted to have
nausea
DISEASE
vomiting epigastric pain
DISEASE
. He was started on D5W gtt. Chem panelshowed an AG of 19 but HCO3 of only 23. Lactate 0.7. She wasgiven Thiamine 100mg PO x 1 Folic Acid 1mg PO x 1 Zofran for
nausea
DISEASE
. Per ED signout pt had ketones in urine though it isunclear as to where the urine findings were noted. He received1L NS and was started on D5NS maintenance fluid and receivedapprox
100cc
DISEASE
. Pt was also guaiac negative in the ED..On the floor pt stated he still had some
abdominal pain
DISEASE
andstill felt as if he was withdrawing. He does not have any
emesis
DISEASE
currently his last episode was several hours ago in the ED. Heis usually seen at [**Hospital 882**] hospital and was recently there 2months ago and hospitalized for a month for Admission Date: [**2164-9-6**] Discharge Date: [**2164-9-12**]Date of Birth: [**2093-1-13**] Sex: FService: MED
Allergies
DISEASE
:Blood Adminstration EquipmentAttending:[**First Name3 (LF) 338**]Chief Complaint:DOE and CPMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:71F with DM HTN Hyperlipidemia who was well until [**9-7**] whenshe noticed LLE swelling. She soon experienced acute onset ofsharp SSCP along with SOB and DOE. At baseline the patient runsher own day care and is fairly active picking up and chasingafter children. She can climb up to nine flights of stairswithout
chest pain
DISEASE
or
chest pain
DISEASE
. She has had no miscarriages orh/o difficulty conceiving. There is no h/o PE or
DVT
DISEASE
. Pt takesno estrogens herbals OTCs and does not use drugs orcigarettes. No recent foreign travel or sick contacts.Found to have large b/l PEs - hemodyn stable since admission.On heparin o/n but access issue. Now on lovenox. Coumadinstarted on admission.ROS: No abd pain bloating F/C weight changes
rash bruising
DISEASE
.Pt has baseline
lumbar pain
DISEASE
worse with walking. She also hashad
upper back pain
DISEASE
which began after her
meningioma
DISEASE
removal 1yr PTA.Past Medical History:
HTN
DISEASE
DMII (
Diet-controlled
DISEASE
)
Hyperlipidemia
DISEASE
S/P Spinal
Meningioma
DISEASE
Resection and
T4-T6
DISEASE
Laminectomy/Fusion S/P CCY
Cataracts
DISEASE
S/P HysterectomySocial History:Lives at home with her daughter and grandaughter. Has fourchildren. Runs day care out of her houseAdmission Date: [**2130-2-3**] Discharge Date: [**2130-2-9**]Date of Birth: [**2060-12-25**] Sex: MService: SURGERY
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 371**]Chief Complaint:Bright red blood per rectumMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:69 yo M presents 8 days s/p anal seton placement with a 24 hourhistory of bright red blood per rectum soaking his clothes. Heturned the toilet water dark red approximately 15 times.Multiple large clots seen. He complains of associated
dizziness
DISEASE
and had
hypotension
DISEASE
in the ED.
Denies fevers chills N/V
DISEASE
orchange in appetite.Past Medical History:1.
Crohn's
DISEASE
dz found in [**2125**] on colonoscopy for
anal fissure
DISEASE
positive [**Doctor First Name **] been treated with Remicade2.
Rheumatoid arthritis
DISEASE
3.
HTN
DISEASE
4. hx of renal calculus5. s/p appendectomy6. s/p TURP7. s/p cholecystectomy8. Recent pulmonary embolism- on coumadin since [**2-12**]9.
LVH LV enlargement apical LV aneurysm
DISEASE
with
LV thrombus
DISEASE
EF25%10.
Chronic left knee pain
DISEASE
s/p meniscectomy synovectomy anddebridement of left knee [**2123**]11. Recent
gallstone pancreatitis
DISEASE
[**2-12**]12.
Afib
DISEASE
- [**2-12**] rate controlled on atenololSocial History:Married for 46 years and lives with wife. 3 children who alllive in area. No tobocco h/o occasional ETOH stopped drinkingin [**11-13**] denies h/o ETOH abuse. No illicit drugs.Family History:Father died at 62 from MIMother died at 52 of
cirrhosis
DISEASE
No
cancer
DISEASE
or
diabetes
DISEASE
to patient's knowledgeNo hisotry of
clotting disorders
DISEASE
Physical Exam:At time of discharge:A&O X 3 NADRRRCTABAbd soft
NT/ND
DISEASE
Admission Date: [**2128-1-11**] Discharge Date: [**2128-1-21**]Date of Birth: [**2057-1-13**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1267**]Chief Complaint:
Chest pain
DISEASE
Major Surgical or Invasive Procedure:[**2128-1-11**] - Cardiac Catheterization[**2128-1-15**] CABGx4 (LIMA-Admission Date: [**2113-4-28**] Discharge Date: [**2113-5-3**]Date of Birth: [**2040-12-26**] Sex: FService: NEUROSURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1271**]Chief Complaint:Sycope fallMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:This is a 72 year old female on aspirin who fell [**2113-4-28**]at home. She states that she felt lightheaded and then nextremembers being on the tiled floor in the kitchen. The fall was
unwitnessed
DISEASE
with reported
loss of consciousness
DISEASE
and the patientdoes not know how long she was down for. She reports 4 episodesof
vomiting
DISEASE
since her fall. She complains of
numbness
DISEASE
andtingling sensation in her hands
weakness
DISEASE
in her hands and legs.She denies
bowel or urine incontinence hearing or visual
DISEASE
deficit.She denies use of assistive devices to ambulate at home.She reports 4 episodes of
lightheadedness
DISEASE
in the past.Past Medical History:
CVA
DISEASE
[**2105**]Social History:The patient lives at home with her husbandPhysical Exam:On admission:PHYSICAL
EXAM
DISEASE
:O: T:96.5 BP: 100/50 HR:54 R: 16 O2Sats: 100%Gen: comfortable NAD.HEENT: 2 cm occipital lac Pupils: 2.5-2mm EOMs: intactNeck: hard cervical collarExtrem: Warm and well-perfused.Neuro:Mental status: Awake and alert cooperative with exam normalaffect.Orientation: Oriented to person place and date.Language: Speech fluent with good comprehension and repetition.Naming intact. No
dysarthria
DISEASE
.Cranial Nerves:I: Not testedII: Pupils equally round and reactive to light 2.5 to 2mm bilaterally. Visual fields are full to confrontation.III IV VI:
Extraocular movements
DISEASE
intact bilaterally without
nystagmus
DISEASE
.V VII: Facial strength and sensation intact and symmetric.VIII: Hearing intact to voice.IX X:
Palatal elevation
DISEASE
symmetrical.[**Doctor First Name 81**]: Sternocleidomastoid and
trapezius
DISEASE
normal bilaterally.XII: Tongue midline without
fasciculations
DISEASE
.Motor: Normal bulk and tone bilaterally. No
abnormal movements
DISEASE
tremors
DISEASE
.Strength Motor: D B T WE WF IP Q H AT [**Last Name (un) 938**] GR 5 5 5 4 4 3 3 4 2 2 2L 5 5 5 4 3 3 3 5 4Admission Date: [**2113-5-3**] Discharge Date: [**2113-5-25**]Date of Birth: [**2040-12-26**] Sex: FService: NEUROSURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1271**]Chief Complaint:Admission Date: [**2152-3-23**] Discharge Date: [**2152-3-31**]Date of Birth: [**2072-12-24**] Sex: MService: CSUHISTORY OF PRESENT ILLNESS: This is a 79-year-old gentlemanwith a longstanding history of
coronary artery disease
DISEASE
. Hehad an initial percutaneous transluminal coronary angioplastyof his left circumflex in [**2137**]. In [**2139**] he had acatheterization that showed 100 percent right coronary arteryocclusion and a subtotal circumflex lesion with apercutaneous transluminal coronary angioplasty done. At thesame time he had a mild left anterior descending occlusionwith some
venous obstruction
DISEASE
.Over the past few months he has had increasing angina withexertion. On [**2152-1-11**] he had an exercise tolerancetest that was positive with ST depressions with
inferoposterior ischemia
DISEASE
. His angina is primarily betweenhis scapula and back. He was referred for cardiaccatheterization which was done on [**2152-1-28**]. Thisrevealed an ejection fraction of 60 percent. He had a mildlydilated aortic root right-dominant system left main with a20 percent occlusion diagonal with 70 percent ramus with 80percent circumflex with 95 percent left anterior descendingwith 70 percent with distal left anterior descending 90percent occlusion obtuse marginal with 80 occlusion rightcoronary artery with 100 percent and posterior descendingartery with 70 percent. No
mitral regurgitation
DISEASE
or aorticstenosis. At that time he was referred for bypass surgery.PAST MEDICAL HISTORY:1.
Glaucoma
DISEASE
.2.
Tuberculosis
DISEASE
.3. Ventral
hernia
DISEASE
.4. Question of
lumbar stenosis
DISEASE
.5.
Coronary artery disease
DISEASE
(with percutaneous transluminal coronary angioplasty in [**2137**] and [**2139**]).6. Left-sided
headaches
DISEASE
(with question of temporal
arteritis
DISEASE
).7.
Left carotid disease
DISEASE
.8.
Diverticulitis
DISEASE
.9.
Hypertension
DISEASE
.10.
Hiatal hernia
DISEASE
with
gastroesophageal reflux disease
DISEASE
.11. Elevated cholesterol.12. Benign
prostatic hypertrophy
DISEASE
.PAST SURGICAL HISTORY:1. Tonsillectomy and adenoidectomy (as a child).2. Colon polypectomy.3. Bilateral laser eye surgery.ALLERGIES: SULFA (causes hot flashes).PHYSICAL EXAMINATION ON PRESENTATION: The patient's heightwas 5 feet 9 inches tall his weight was approximately 175pounds blood pressure in the left arm was 180/66 and hisright arm blood pressure was 188/80. Cardiovascularexamination revealed a rate and rhythm. Normal first heartsounds and second heart sounds. There was a 2/6 systolicejection murmur. The lungs were clear to auscultationbilaterally. The abdomen was soft nontender andnondistended. Left upper quadrant diverticula and ventral
hernia
DISEASE
. Extremities were warm and well perfused. There wereno varicosities. Good circulation sensation mobility.Pulse examination revealed right and left femoral were 2plus right and left dorsalis pedis pulses were 2 plus rightand left posterior tibialis were 2 plus and right and leftradial pulses were 2 plus. Neurologically the pupils wereequal round and reactive to light and accommodation.
Cranial nerves II
DISEASE
through XII were grossly intact. Anonfocal examination. Head eyes
ears nose
DISEASE
and throatexamination revealed the
extraocular movements
DISEASE
were intact.The sclerae were anicteric and not injected. There werebuccal mucosa. Neck examination revealed there was no
jugular venous distention
DISEASE
. There were no
bruits
DISEASE
.PERTINENT LABORATORY VALUES ON THE DAY OF DISCHARGE: Whiteblood cell count was 10.2 his hematocrit was 32.9 and hisplatelets were 349. Potassium was 4.7 his blood ureanitrogen was 16 and his creatinine was 0.8.PERTINENT RADIOLOGY/IMAGING: Last chest x-ray revealed asmall bilateral effusion. No
congestive heart failure
DISEASE
. No
pneumothorax
DISEASE
.BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admittedon [**3-23**] and underwent a coronary artery bypass graft timesthree. He was extubated that afternoon. He was initially A-paced at 80 with an underlying
sinus bradycardia
DISEASE
at a rate of50.On postoperative day three he went into
atrial flutter
DISEASE
.After 5 mg of intravenous Lopressor he had a nine secondpause with conversion to a sinus rhythm. That day he hadthree subsequent pauses of about six seconds each and theElectrophysiology Service was consulted. On [**3-26**] he hadsome
atrial fibrillation
DISEASE
and
atrial flutter
DISEASE
with a rate inthe 80s to 90s.On the evening of [**3-27**] he went into an acceleratedidioventricular rhythm and was subsequently A-paced at 80.He continued in a normal sinus rhythm with some episodes ofaccelerated idioventricular rhythm but he was asymptomatic.On [**3-27**] the patient was started on 12.5 mg of by mouthLopressor (per Electrophysiology). They did not recommend apacemaker or defibrillator placement.The patient was transferred to the inpatient floor on [**3-29**].His chest tubes had been removed on [**3-26**] and his cardiacpacing wires were removed on [**3-29**]. He had been followedthroughout his hospital course by the Physical TherapyService. His chest tubes had come out on the [**3-26**]. Thepatient was cleared for home by the Physical Therapy Serviceon [**3-30**].CONDITION ON DISCHARGE: Vital signs revealed his pulse was65 (in a sinus rhythm) his blood pressure was 138/64 hisrespiratory rate was 18 and his oxygen saturation was 95percent on room air. His temperature maximum was 99.3degrees Fahrenheit. His weight on discharge was 79kilograms. Preoperatively 79 kilograms as well. The patientwas alert awake and oriented times three. The sternalincision was clean dry and intact with a stable sternum.Bilateral lower extremity vein harvest sites were clean dryand intact with moderate
ecchymosis
DISEASE
on the right thigh.Cardiovascular examination revealed a rate and rhythm.Respiratory examination revealed the lungs sounds were clear.There were scattered rhonchi on the right side.Gastrointestinal examination revealed there were positivebowel sounds. The abdomen was soft nontender andnondistended. Extremity examination revealed some tracelower extremity
edema
DISEASE
.DISCHARGE STATUS: The patient was discharged to home withVisiting Nurses Association on [**3-30**] in stable condition.DISCHARGE DIAGNOSES:1. Coronary artery diseaseAdmission Date: [**2115-10-29**] Discharge Date: [**2115-11-16**]Service: [**Hospital Unit Name 196**]
Allergies
DISEASE
:Vitamin K / NiacinAttending:[**Location (un) 1279**]Chief Complaint:
Coronary Artery Disease
DISEASE
Major Surgical or Invasive Procedure:Left
CCA
DISEASE
punctureIntubationHistory of Present Illness:81 y/o M with critical AS and 3VD who presents for
CHF
DISEASE
exacerbation. Pt transferred from [**Hospital3 1280**] after ruling infor AMI and was awaiting
CABG/AVR
DISEASE
. Pre-operative coursecomplicated by MRSA UTI and L
SCV thrombosis
DISEASE
. Pt noted to haveincidental L
CCA
DISEASE
puncture during IJ central venous accessattempt. This was likely due to a
goiter
DISEASE
found later in thehospital course.Past Medical History:DM
HTN
DISEASE
Bladder CAPertinent Results:[**2115-11-16**] 06:15AM BLOOD WBC-11.4* RBC-4.04* Hgb-13.0* Hct-37.7*MCV-93 MCH-32.2* MCHC-34.5 RDW-12.7 Plt Ct-354[**2115-11-15**] 05:54AM BLOOD Neuts-88.9* Lymphs-6.3* Monos-4.6 Eos-0.1Baso-0[**2115-11-16**] 06:15AM BLOOD Plt Ct-354[**2115-11-15**] 05:54AM BLOOD PT-13.4 PTT-24.3 INR(PT)-1.1[**2115-11-16**] 06:15AM BLOOD Glucose-84 UreaN-54* Creat-1.1 Na-140K-4.2 Cl-99 HCO3-29 AnGap-16[**2115-11-12**] 06:05AM BLOOD ALT-62* AST-73* LD(LDH)-246 AlkPhos-106
TotBili-0.8
DISEASE
[**2115-11-7**] 07:21AM BLOOD CK(CPK)-132[**2115-11-6**] 11:34PM BLOOD CK(CPK)-138[**2115-11-7**] 07:21AM BLOOD CK-MB-6 cTropnT-0.17*[**2115-11-16**] 06:15AM BLOOD Calcium-9.9 Mg-1.8[**2115-11-15**] 05:54AM BLOOD
Calcium-9.8
DISEASE
Phos-4.3 Mg-1.9[**2115-10-29**] 07:42PM BLOOD %HbA1c-5.3[**2115-11-14**] 07:00AM BLOOD TSH-0.55[**2115-11-14**] 07:00AM BLOOD Free T4-1.9*Brief Hospital Course:1. Cardiac: Pt with 3VD cath'd at [**Hospital3 1280**] that showed 80%prox LAD 80% D2 80% prox LCx involving ostium and patent RCAwith stent. Mid PDA with 50% stenosis. Pt also with critical ASwith valve area 0.7cm squared with mean gradient 60mmHg. Thept's pre-op course was complicated by MRSA UTI which was treatedwith vanc without problem. The pt was found to have decreasedBP's in the LUE and hx LUE claudication subsequently found tohave L
SCV stenosis
DISEASE
by arteriography which was not intervenedon. The pt went to the OR for CABG and
AVR/MVR
DISEASE
[**2115-11-6**] whenhis L common carotid artery was punctured during IJ venousaccess attempt. The
bleeding
DISEASE
was controlled with pressure andthe pt was intubated for airway control. During this processthe pt was administered fluid resuscitation and went into acute
pulmonary edema
DISEASE
. The CCU team was called took over the pt'scare. He was diuresed aggressively with IV lasix drip andnitroglycerin drip for unloading. Pt extubated [**2115-11-7**] with [**Last Name **]problem. CT surgery feels the patient should wait at least 8weeks from time of discharge to CABG because of increased
bleed
DISEASE
risk from
CCA
DISEASE
puncture.2. Rhythm: The pt was noted to be in Mobitz I HB withborderline prolonged PR and
atrial ectopy
DISEASE
. He was evaluated bythe EP service who felt this problem should be addressed as anoutpt. He will have f/u for potential pacemaker device afterCABG.3. UTI: The pt had a MRSA UTI while in house. He wassuccessfully treated with 7 day course of vancomycin. F/U UA'shave been negative for persistence of
infection
DISEASE
.4. CCA puncture: Occurred during IJ attempt in OR. Likelyoccurred secondarily to large thyroid mass interfering withgreat vessel anatomy (see below). Doppler son[**Name (NI) 867**] found a
fistula
DISEASE
between the L
CCA
DISEASE
and IJV. Vascular surgery followedthe patient and did not feel the
fistula
DISEASE
would requireintervention. Serial dopplers reveal a decrease in the size ofthe
fistula
DISEASE
encouraging for eventual spontaneous closure.Mr.[**Known lastname **] did require one unit of PRBC for
anemia
DISEASE
thought to besecondary to this
bleeding
DISEASE
.5. Thyroid Mass: Found on chest CT. Thyroid ultrasoundrevealed a 4X5cm posterior heterogenous thyroid mass that wasnot biopsied based on pt's coughing during procedure. TSH 0.55with free T41.9. Likely represents a
multinodular
DISEASE
non-toxic
goiter
DISEASE
. Pt should be seen by an endocrinologist prior to CABG.6. Elevated R Hemidiaphragm: Found on routine CXR.Ultrasonographic sniff test revealed diminished (but present)right diaphragmatic excursion. CT chest showed RLL collapsewith mucus plug in RLL bronchus. Aggressive chest PT initiated. Insentive spirometry was already being used since admission.Pt does follow a pulmonologist at [**Location (un) 47**] [**Hospital1 1281**] for thisproblem which has been present for years.7.
Gout
DISEASE
: Pt noted to have erythematous swollen warm R-sidedhand and foot oligo-arthritis consistent with
gouty
DISEASE
flare.Rheumatology consulted suggested 3 week prednisone taper.Discharge Medications:1. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO QD (once aday) for 3 days.Disp:*9 Tablet(s)* Refills:*0*2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD(once a day).Disp:*30 Tablet(s)* Refills:*2*3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).Disp:*30 Tablet(s)* Refills:*2*4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once aday).Disp:*30 Tablet(s)* Refills:*2*5. Lisinopril 20 mg Tablet Sig: Four (4) Tablet PO QD (once aday).Disp:*120 Tablet(s)* Refills:*2*6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every24 hours) for 5 days.Disp:*5 Tablet(s)* Refills:*0*7. Metoprolol Succinate 100 mg Tablet Sustained Release 24HRSig: Three (3) Tablet Sustained Release 24HR PO QD (once a day).Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HRSig: One (1) Tablet Sustained Release 24HR PO QD (once a day).Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*9. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD(once a day).Disp:*60 Tablet(s)* Refills:*2*10. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a dayfor 5 days.Disp:*10 Tablet(s)* Refills:*0*11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a dayfor 3 days.Disp:*3 Tablet(s)* Refills:*0*12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for3 days.Disp:*3 Tablet(s)* Refills:*0*13. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO once a dayfor 3 days.Disp:*3 Tablet(s)* Refills:*0*Discharge Disposition:Home With ServiceFacility:Centrus Home CareDischarge Diagnosis:3VD with critical ASDischarge Condition:GoodDischarge Instructions:Come to the ER if you have these symptoms:1.
chest pain
DISEASE
2. shortness of breath3. fluttering in your chest4. fainting5. darkening of your visionFollowup Instructions:Please call Dr[**Doctor Last Name 1282**] office for an appointment.Please call your primary care physician and schedule anappointment (call [**11-18**]) for [**11-19**].Completed by:[**2115-12-4**]Admission Date: [**2115-12-23**] Discharge Date: [**2116-1-25**]Service: CARDIOTHORACIC
Allergies
DISEASE
:Vitamin K / NiacinAttending:[**First Name3 (LF) 1283**]Chief Complaint:CAD 3 vessel CAD Aortic Stenosistoxic
multinodular goiter CHF
DISEASE
exacerbationMajor Surgical or Invasive Procedure:Operative Note #[**Numeric Identifier 1284**] - CCCName: [**Known lastname **] [**Known firstname **] Unit No: [**Unit Number 1285**]Service:
CSU
DISEASE
Date: [**2115-12-25**]Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1286**] MD 2178FIRST ASSISTANT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] RESPREOPERATIVE DIAGNOSIS:
Toxic multi-nodular goiter
DISEASE
with leftmajor substernal component.POSTOPERATIVE DIAGNOSIS:
Toxic multi-nodular goiter
DISEASE
withleft major substernal component.PROCEDURE PERFORMED: Left sternal thyroidectomy with sternalsplit.[**Known lastname **][**Known firstname **]: [**Hospital1 18**] Notes Detail - CCC Record #[**Numeric Identifier 1285**]Operative Note #[**Numeric Identifier 1287**] - CCCName: [**Known lastname **] [**Known firstname **] Unit No: [**Unit Number 1285**]Service:
CSU
DISEASE
Date: [**2115-11-6**]Surgeon: [**Doctor Last Name **] [**Last Name (Prefixes) **] M.D. [**MD Number(1) 1288**]PREOPERATIVE DIAGNOSIS:
Coronary artery disease
DISEASE
aorticstenosis severe
mitral regurgitation
DISEASE
moderate peripheral
vascular disease
DISEASE
hypertension
DISEASE
.POSTOPERATIVE DIAGNOSIS:
Coronary artery disease
DISEASE
aorticstenosis severe
mitral regurgitation
DISEASE
moderate peripheral
vascular disease
DISEASE
hypertension
DISEASE
.OPERATION: Case planned for an aortic valve replacementmitral valve replacement and coronary artery bypass graftcancelled secondary to
intraoperative carotid injury
DISEASE
duringleft internal jugular vein Swan introducer placement byanesthesia.PROCEDURE: Mr. [**Known lastname **] was to undergo a possible multivalvecoronary artery bypass graft today. After anesthesia thepatient was having an left internal jugular vein Swan Ganzintroducer catheter placed using the Seldinger technique byanesthesia. After confirmation of placing the wire into thesuperior vena cava they were unable to pass the dilator.Upon withdrawal of the dilator brisk red blood was comingout the small skin incision that appeared to be pulsatile.Immediately direct pressure was applied and an intraoperativevascular surgery consult was obtained. It took approximately25 to 30 minutes for pressure to achieve excellenthemostasis.Intraoperative Duplex ultrasound of the carotid showedantegrade flow with a very small low flow left carotid toleft internal
jugular vein fistula
DISEASE
. It was felt by thevascular surgeon that this would probably thrombose on itsown and would be re-evaluated within the next day.Given the nature of the injury and the patient being avasculopath we elected to obtain a neurology consult as wellas attempt to wake the patient up. After reversal of thechemical
paralysis
DISEASE
and sedation the patient did in fact moveall of his extremity to command and perform complex tasks.The patient was therefore extubated and appeared to beneurologically intact.At[**Last Name (STitle) 1289**]time the case was cancelled and the patient will bebrought back to the intensive care unit for criticalmonitoring of all organ systems. Dr. [**Last Name (Prefixes) **] was presentand participated throughout all significant portions of hispreoperative care.[**2115-12-25**] Dr. [**Last Name (STitle) 1290**] [**Name (STitle) 1291**]/ CABG x 3History of Present Illness:81 yo male admitted [**2115-12-23**]from OSH with recent
CHF
DISEASE
exacerbation severe 3 VD severe ASwith CABG/MVR/[**Month/Day/Year 1291**] postponed due to carotid puncture and thenpre-op course c/b L SCV
thrombosis
DISEASE
pulmonary edema
DISEASE
elevated Rhemidiaphragm due to RLL collapse & mucous plug and dx of toxic
multinodular goiter
DISEASE
. [**2115-12-28**] pt underwent CABG/[**Month/Day/Year 1291**] not MVRand left thyroidectomy. [**12-30**]- pt was extubated but on [**1-2**] -ptwas reintubated due to
fatigue
DISEASE
. [**2116-1-7**]- pt was extubated.Pt hasbeen NPO since that time on NG tube feedings. getting excellentphysical therapy and progression from deabiliation related toprolonged ICU stayPast Medical History:PAST MEDICAL HISTORY:1.
Coronary artery disease
DISEASE
status post RCA stent in [**2103**]An exercise tolerance test/SPECT ([**6-1**]) demonstrated inferiorinferoseptal inferoapical defects without symptoms butischemicelectrocardiographic changes.2. Moderate AS. Transthoracic echocardiogram done [**2112-5-31**]showedejection fraction 60 percent left
ventricular hypertrophy
DISEASE
mild
aortic insufficiency
DISEASE
moderate
aortic stenosis
DISEASE
with [**Location (un) 109**]0.98 cm sq peak gradient 50 mmHg mean gradient 27 mmHg.3.
Peripheral vascular disease
DISEASE
with lower extremityclaudication and status post CEA.4.
Bladder cancer
DISEASE
status post
tumor
DISEASE
excision two years agobiopsy last month. Patient unaware of results. No pastchemotherapy or radiation therapy.5. Sciatica treated with Neurontin.6.
CHF
DISEASE
.7. DM8. 1rst degree AVB9.
Gout
DISEASE
PAST SURGICAL HISTORY: Status post right carotidendarterectomy five years ago status post right femoralpopliteal bypass five years ago.Social History:SHx: Quit smoking 10y ago after 20 years hx of heavy smoking.Family History:FHx: father CAD pt unsure of age.Physical Exam: Elderly maleVS: *100/70 L arm *168/82 R armHR 72 sat 100%
RA
DISEASE
neck: Admission Date: [**2130-12-15**] Discharge Date: [**2130-12-18**]Date of Birth: [**2057-10-30**] Sex: MService:DIAGNOSIS: Sepsis.HOSPITAL COURSE: (Summary of the patient's medicineIntensive Care Unit course from [**2130-12-15**] until[**2130-12-18**])HISTORY OF PRESENT ILLNESS: The patient is a 73 year oldmale with recently diagnosed
nonHodgkin's lymphoma
DISEASE
in[**2130-9-11**]. The patient presented with
low back pain
DISEASE
and was found to have a poor compression. The patient wastreated with radiation and steroids from [**Month (only) **] until[**2130-10-18**] and then discharged to [**Hospital **]Rehabilitation for rehabilitation. The patient wasreadmitted on [**2130-11-8**] for Rituxan treatment peroncology Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. After receiving first dose ofRituxan the patient had an adverse reaction including
hypotension tachycardia fever
DISEASE
and
hypoglycemia
DISEASE
. Thehospital course was notable for syndrome of inappropriateantidiuretic hormone change in mental status and
anemia
DISEASE
.The patient was then discharged to [**Hospital1 **] on [**2130-11-12**]. The patient now returns to the Emergency Room on theday of admission with
lethargy
DISEASE
and
shortness of breath
DISEASE
. Thepatient has been undergoing treatment with Levofloxacin forpresumed
pneumonia
DISEASE
since [**12-11**]. At [**Hospital1 **] the patientwas short of breath and was given in addition to LevofloxacinVancomycin for treatment of presumed
pneumonia
DISEASE
and referredto the Emergency Room. In the Emergency Room the patient hada temperature of 100.8 and was
hypotensive
DISEASE
with a systolicblood pressure of 77. In addition the patient was in mild
respiratory distress
DISEASE
and was hypoxic with an oxygensaturation of 88% on 4 liters. The patient was diagnosedwith presumed
sepsis
DISEASE
from
pneumonia
DISEASE
and started onintravenous fluid resuscitation and sent to the IntensiveCare Unit.PAST MEDICAL HISTORY: 1. NonHodgkin's lymphoma as perhistory of present illness follicular. 2. Type 1
diabetes
DISEASE
.3. Benign
prostatic hypertrophy
DISEASE
. 4. Anemia. 5.
Depression
DISEASE
.MEDICATIONS ON ADMISSION:1. Celexa 20 mg p.o. q.d.2. Aranesp 100 mcg q. weekly3. Colace 100 mg p.o. b.i.d.4. Lantis insulin 10 units q. PM5. Prevacid 30 mg p.o. q.d.6. Magnesium oxide 400 mg p.o. q.d.7. Remeron 15 mg p.o. q.h.s.8. Multivitamin one tablet p.o. q.d.9. Senna two tablets p.o. q.d.10. Levaquin 500 mg p.o. q.d. started on [**2139-12-16**]. Humalog sliding scale 201 to 250 2 units 251 to 300 4units 301 to 350 6 units 351 to 400 8 units 401 to 450 12units 451 to 500 15 units.ALLERGIES: Rituxan.SOCIAL HISTORY: The patient is single has no children. Thenext closest [**Doctor First Name **] is his brother. Lives alone prior to recentillnesses.PHYSICAL EXAMINATION ON ADMISSION: General: Alert andoriented to person hospital and year but drowsy. Headeyes ears nose and throat oropharynx with dry mucousmembranes no jugulovenous distension. Cardiovascularregular rate and rhythm with no murmurs. Lungs with cracklesat bases bilaterally. Abdomen soft nontendernondistended. Positive
hepatomegaly
DISEASE
. Spleen not palpated.Extremities no
edema
DISEASE
2Admission Date: [**2130-12-15**] Discharge Date: [**2130-12-21**]Date of Birth: [**2057-10-30**] Sex: MService: MedicineADDENDUM TO [**2130-12-18**] DISCHARGE SUMMARY - SUMMARY OF HOSPITALCOURSE FOLLOWING MICU CALL OUT: In summary this is a73-year-old male with a history of
non-Hodgkin's lymphoma
DISEASE
cord compression depression
DISEASE
BPH who was transferred to[**Hospital1 18**] for
sepsis
DISEASE
and
respiratory failure
DISEASE
treated in the ICUand called out to the floor with resolving respiratoryfailure
sepsis
DISEASE
with a presumed
pneumonia
DISEASE
. Please see abovedictation for ICU course.1) SEPSIS: The patient was called out from the MICU withresolving
sepsis
DISEASE
. He remained hemodynamically stable on thefloor. The patient finished his 7-day course ofhydrocortisone was continued on Levofloxacin IV withtransition to PO and continued on vancomycin. Sepsis waspresumed to be due to underlying
pneumonia
DISEASE
as evidenced bychest x-ray though no organisms was ultimately identified ineither the blood sputum or urine. Prior PICC line sitecatheter tip was also negative.2) PNEUMONIA: The patient was treated for bilateralinterstitial fluffy infiltrates on chest x-ray. Differentialdiagnosis including atypicals and PCP. [**Name10 (NameIs) **] patient improvedclinically on broad-spectrum antibiotics initially andsubsequently continued on Levaquin and vancomycin. There wassome initial suggestion that the chest x-ray lookedconsistent with PCP [**Name10 (NameIs) 3**] the patient had been on long-termsteroids for
cord compression
DISEASE
. However the patientclinically improved without bactrim or treatment for his
Pneumocystis carinii
DISEASE
for suspected PCP [**Name Initial (PRE) 1064**]. Thepatient will be discharged on a 7-day course of Levofloxacin500 mg po qd and vancomycin 1 gm IV q 12 h x 7 days. Thepatient will be discharged on prophylactic dose of bactrimas the patient will continue decadron 4 mg po qd for cordcompression and for continued treatment of
non-Hodgkin's
lymphoma
DISEASE
. On discharge the patient was breathingcomfortably on room air with resolved
respiratory failure
DISEASE
.3) TYPE 2 DIABETES INSULIN DEPENDENT: The patient's bloodsugars were relatively uncontrolled during his hospital stayas the patient was given IV steroids as part of the
sepsis
DISEASE
protocol. The patient's Lantus dose was increased to 20 U qhs with an aggressive Humalog sliding scale and on the dayof discharge blood sugars remained in the 150s-250 range.The patient will need careful follow-up as high-dose steroidswill be discontinued on the day of discharge with assessmentof blood sugar and need to titrate down on the Lantus andHumalog as needed.4) NON-HODGKIN'S LYMPHOMA: The patient will be continued tobe followed at [**Hospital1 **] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for continuedmanagement of his
non-Hodgkin's lymphoma
DISEASE
. The patient willbe discharged on decadron 4 mg po qd.5) ANEMIA: The patient was transfused 2 units for acute
blood loss
DISEASE
in the ICU. The patient's hematocrit remainedgreater than 30. On discharge the patient will continue hisEpogen 4000 units twice a week for persistent and chronic
anemia
DISEASE
.6) DEPRESSION: The patient's affect was relatively flat withsome evidence of paranoia. He will continue on hiscitalopram 20 mg po qd with follow-up with his primary carephysician for further management.7) DECONDITIONING: The patient has a long history ofrehabilitation inactivity and loss of function secondary to
cord compression
DISEASE
. Cord compression has improved perinformation from his prior extended care facility. He willneed aggressive physical therapy and occupational therapy athis new extended care facility.DISCHARGE CONDITION: Stable. The patient is breathingcomfortably on room air attempting ambulation withassistance and tolerating PO.DISCHARGE STATUS: The patient is expected to be dischargedto the [**Hospital1 **] acute care facility for rehabilitation withtransfer to lower level care as needed.DISCHARGE DIAGNOSES:1.
Sepsis
DISEASE
.2.
Respiratory failure
DISEASE
.3.
Pneumonia
DISEASE
bacterial unspecified.4. Type 2
diabetes
DISEASE
uncontrolled.5.
Anemia
DISEASE
acute
blood loss
DISEASE
.6.
Lymphoma
DISEASE
.7. Failure to thrive and deconditioning.DISCHARGE MEDICATIONS:1. Tylenol 325-650 mg po q 4-6 h prn
pain
DISEASE
.2. Pantoprazole 40 mg po qd.3. Heparin subcu 5000 U q 8 h.4. Citalopram 20 mg po qd.5. Mirtazapine 50 mg po q hs.6. Epoetin Alfa 4000 U 2 x week--Monday Thursday.7. Colace 100 mg po bid--hold for loose stools.8. Senna 1-2 tabs po bid--hole for loose stools.9. Levofloxacin 500 mg po qd x 7 days.10.Lantus 20 U subcutaneous at bedtime.11.Humalog sliding scale.12.Decadron 4 mg po qd.13.Bactrim 1 tab qd for PCP [**Name Initial (PRE) 1102**].FOLLOW-UP:1. The patient will continue to have his oncology carecoordinated via Dr. [**First Name (STitle) **] at [**Hospital1 **].2. The patient will have a new primary care physician [**Last Name (NamePattern4) **].[**First Name8 (NamePattern2) **] [**Name (STitle) 1299**] at [**Company 191**] Associates telephone# ([**Telephone/Fax (1) 1300**].First appointment is [**2131-1-22**] at 1:30 pm at [**Hospital3 1301**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1302**] M.D.Dictated By:[**Last Name (NamePattern1) 1303**]MEDQUIST36D: [**2130-12-21**] 11:06T: [**2130-12-21**] 11:17JOB#: [**Job Number 1304**]Admission Date: [**2166-11-11**] Discharge Date: [**2166-11-13**]Date of Birth: [**2110-4-10**] Sex: MService: [**Company 191**] MED.CHIEF COMPLAINT: Hematocrit drop from 30 to 23 over theperiod of one week.HISTORY OF THE PRESENT ILLNESS: This a 56-year-old male with
end-stage renal disease
DISEASE
status post cadaveric renaltransplant times three with recent ileostomy reversal on[**2166-10-21**]. He presents with generalized
fatigue
DISEASE
anddecreased hematocrit from 30 to 23 over one week while inrehabilitation. The patient's history dates back to [**6-13**]at which time he underwent colonoscopy for
bleeding
DISEASE
polypswhich was complicated by
valve perforation
DISEASE
of the cecum. Hewas taken to the operating room for emergent right ilealcystectomy with Hartmann pouch and end ileostomy in the rightlower quadrant. The patient underwent ileostomy reversal on[**2166-10-21**] without complication. The patient returned to[**Hospital1 69**] on [**2166-10-31**] two daysafter discharge from the hospital with complaints of
nausea
DISEASE
vomiting
DISEASE
and
bloating
DISEASE
. He was felt to have postoperative
ileus
DISEASE
. He was discharged to rehabilitation on [**2166-11-5**].At rehabilitation he was noticed to have a decreasedhematocrit as well as
fatigue
DISEASE
. He had no
chest pain
DISEASE
shortness of breath
DISEASE
or light
headedness
DISEASE
no
melena
DISEASE
no
hematochezia
DISEASE
no
nausea vomiting
DISEASE
or
abdominal pain
DISEASE
no
fevers chills
DISEASE
or
rash
DISEASE
.Examination revealed the patient afebrile with a heart rateof 72 blood pressure of 162/64. He had heme-positive brownstool. He had NG lavage of 600 cc showing stomach contentsand negative for blood. The patient was also noted to have acalcium of 5.9 at that time. However he did have a lowalbumin. He also had a positive urinalysis. He received oneunit of packed red cells in the emergency department. Healso received 2-g of calcium gluconate.PAST MEDICAL HISTORY:1. Renal transplant cadaveric times three in [**2134**] [**2158**]and [**2161**] on chronic immunosuppression includingcephalosporins steroids and CellCept.2. Chronic
renal insufficiency
DISEASE
.3. Coronary artery disease status post MI in [**2160**] statuspost stent.4. Peripheral neuropathy secondary to hemodialysis.5. Gastroesophageal reflux disease.6. Bilateral hip replacement and left shoulder replacementsecondary to
steroid-induced
DISEASE
avascular necrosis.7. Right foot
cellulitis
DISEASE
on 6/[**2164**].8.
Hypertension
DISEASE
.9. Hemicolectomy as per history of present illness.10. Echocardiogram [**3-/2163**] showed akinesis of theinferoposterior wall mild LV dilation EF 40% to 45%.11. History of alcohol abuse.12. History of
seizures
DISEASE
.13. Status post subtotal parathyroidectomy.SOCIAL HISTORY: The patient is currently staying [**Hospital 1315**] Rehabilitation. He does not smoke. He is a formerbinge drinker. He quit in [**2160**]. He is single.FAMILY HISTORY: History is positive for
stroke
DISEASE
in agrandparent.MEDICATIONS:1. Cyclosporin 175 mg in the morningAdmission Date: [**2168-1-27**] Discharge Date: [**2168-2-3**]Date of Birth: [**2110-4-10**] Sex: MService:HISTORY OF THE PRESENT ILLNESS: The patient is a 57-year-oldman with complaints of lower leg weakness times two years.He had a T12-L3 laminectomy done by Dr. [**Last Name (STitle) 1338**] two years agoand however has had left leg
pain
DISEASE
and
weakness
DISEASE
persistentlysince that surgery. He saw Dr. [**Last Name (STitle) 1327**] in [**2167-11-13**]with complaints of
pain
DISEASE
originating in his midback andradiating down both legs with
pain
DISEASE
especially in the left legand worsening right leg. He has also complained of
numbness
DISEASE
in the left leg worse than the right. The
numbness
DISEASE
includesboth legs and thighs. He says occasionally it is hard toinitiate
urination
DISEASE
. Also he has had urinary frequency.PAST MEDICAL HISTORY:1. Cholecystectomy.2. GERD.3. Subtotal parathyroidectomy.4. Status post L5 laminectomy with fusion.5. Hepatitis C.6. Status post
UTIs
DISEASE
.7.
Hypertension
DISEASE
.8. CAD.9. MI in [**2160**].10.
Renal failure
DISEASE
status post cadaveric renal transplanttimes three most recently in [**2161**].11. Coronary artery stent on the right.12. Bilateral hip replacements.13.
Anemia
DISEASE
.PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Stable. Hewas afebrile. He was awake alert and oriented times three.His pupils were equal round and reactive to light. EOMsfull. Face symmetric. His strength in his lower extremitiesrevealed that he was 4- in the right IP 4Admission Date: [**2119-5-4**] Discharge Date: [**2119-5-25**]Service: CARDIOTHORACIC
Allergies
DISEASE
:AmlodipineAttending:[**Last Name (NamePattern1) 1561**]Chief Complaint:81 yo F smoker w/
COPD
DISEASE
severe TBM s/p tracheobronchoplasty [**5-5**]s/p perc trach [**5-13**]Major Surgical or Invasive Procedure:bronchoscopy 3/314/23[**6-12**] [**5-17**] [**5-19**]s/p trachealplasty [**5-5**]percutaneous tracheostomy [**5-13**] after failed extubationdown size trach on [**5-25**] to size 6 cufflessHistory of Present Illness:This 81 year old woman has a history of
COPD
DISEASE
. Over the past fiveyears she has had progressive difficulties with her breathing.In[**2118-6-4**] she was admitted to [**Hospital1 18**] for
respiratory failure
DISEASE
dueto a
COPD
DISEASE
exacerbation. Due to persistent
hypoxemia
DISEASE
sherequiredintubation and a eventual bronchoscopy on [**2118-6-9**] revealed markednarrowing of the airways on expiration consistent withtracheomalacia.She subsequently underwent placement of twosilicone stents one in the left main stem and one in thetrachea. During the admission the patient had complaints ofchest
pain
DISEASE
and ruled out for an MI. She was subsequently discharged to[**Hospital1 **] for physical and pulmonary rehab. Repeat bronchoscopyon[**2118-8-1**] revealed granulation tissue at the distal right lateralwall of the tracheal stent. There was significant malacia of theperipheral and central airways with complete collapse of theairways on coughing and forced expiration. Small nodules werealso noted on the vocal cords. She has noticed improvement inherrespiratory status but most recently has been in discussionwith Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] regarding possible tracheobronchial plastywith mesh. Tracheal stents d/c [**2119-4-19**] in anticipation ofsurgery.In terms of symptoms she describes many years of intermittent
chest pain
DISEASE
that she describes as left sided and occurring at anytime. Currently she notices it about three times a week andstates that it seems to resolve after three nitroglycerin.She currently is dependent on oxygen and wears 1.5-2 litersaround the clock. She has frequent coughing and brings up Admission Date: [**2131-6-28**] Discharge Date: [**2131-7-5**]Date of Birth: [**2060-12-25**] Sex: MService: MEDICINE
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 678**]Chief Complaint:Mr. [**Known lastname 2302**] is a 70 y.o. male with hx of
Crohn's disease
DISEASE
afib
dilated CMP
DISEASE
and PE (on coumadin) who presents withhematochezia/BRBPR in setting of INR 7.7.Major Surgical or Invasive Procedure:Colonoscopy w/ multiple BxHistory of Present Illness:Patient had felt well during the last 2 weeks prior toadmission although he had noticed slightly red/pink tinge tohis stool occasionally. Three days prior to admission pt hadan INR of 2.7 at coumadin clinic. One day prior to presenationthe patient self-started asacol from previous prescriptionbecause worsening of rectal chrone's disease. On day ofpresentation pt began having dark red bloody BMs had Admission Date: [**2130-12-24**] Discharge Date: [**2130-12-31**]Date of Birth: [**2051-1-26**] Sex: MService: MEDICINE
Allergies
DISEASE
:Amiodarone / Quinidine / Procainamide / Quinine / CodeineAttending:[**First Name3 (LF) 425**]Chief Complaint:
hypotension hyperkalemia
DISEASE
Major Surgical or Invasive Procedure:Hemodialysis catheter placementHistory of Present Illness:Mr. [**Known lastname 1349**] is a 78-year-old male with a history of ventricular
fibrillation arrest
DISEASE
in [**2108**] status post ICD placement dilated
cardiomyopathy
DISEASE
atrial fibrillation hypertension
DISEASE
and
CVA
DISEASE
who presented to the[**Hospital1 18**] ED complaining of 8 lb
weight gain
DISEASE
with increased
edema
DISEASE
ofLE over one week despite compliance with medications. Decreasedpo intake over past week. No SOB
chest pain syncope fatigue
DISEASE
.Found to be
hypotensive
DISEASE
and
hyperkalemic
DISEASE
in the ED. ROSpositive for
epistaxis
DISEASE
(was taking Afrin for this) occasional
nausea
DISEASE
and nonbloody/nonbilious vomitting.Past Medical History:1.
Ventricular fibrillation arrest
DISEASE
in [**2108**] - has had ICDplacement.2.
Dilated cardiomyopathy
DISEASE
. Echocardiogram in [**2126-2-27**]showed an ejection fraction of 20% with inferoapicalhypokinesis plus right ventricular hypokinesis.3.
Atrial fibrillation
DISEASE
status post DC cardioversion in[**2114**] on coumadin.4.
Hypertension
DISEASE
.5. Hypothyroidism.6. Cerebral vascular accident in [**2117**].7.
Rheumatoid arthritis
DISEASE
.8. Positive
lupus
DISEASE
anticoagulant.Social History:Mr. [**Known lastname 1349**] lives with his wife. [**Name (NI) **] denies any tobacco or druguse. He does note occasional alcohol use.Physical Exam:T 97.0. Blood pressure 84/54. Heart rate 81. Respiratory rate10. Oxygensaturation 100% on
RA
DISEASE
. In general in no acutedistress alert and oriented times three
overweight
DISEASE
man. Headeyes ears nose and throat: Normocephalic atraumatic. Pupilsare equalround and reactive to light and accommodation. Oropharynxis pink without lesions mucous membranes
dry
DISEASE
. Nares with
dry
blood.
DISEASE
Neck is supple. Unable to determine JVD secondary toexcess soft tissue at neck. No
lymphadenopathy
DISEASE
. Chest clear toauscultationbilaterally. Cardiovascular: RRR S1 S2are faint. A 2/6
systolic ejection murmur
DISEASE
at the apex.Abdomen soft nontender nondistended. Extremities: 1Admission Date: [**2168-4-5**] Discharge Date: [**2168-4-20**]Date of Birth: [**2127-1-17**] Sex: MService: ORTHOPAEDICS
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Doctor Last Name 1350**]Chief Complaint:Transferred from OSH intubated with progressive loss offunction. Found to have cerivcal
discitis
DISEASE
epidural abscesspharangeal
abscesses
DISEASE
and
bacteremia
DISEASE
.Major Surgical or Invasive Procedure:[**2168-4-5**] C5-T1 lami for epidural abscess - White[**2168-4-8**] ACDF posterior I&D[**2168-4-11**] C3-T1 PISF L ICBG Incisional Vac[**4-14**] Trach and PEG[**4-18**] Right PICC line placementHistory of Present Illness:HPI: 41M h/o IVDA with 3d progressive neck and upper back
pain
DISEASE
and 1d of rapidly progressive UE/LE weakness numbness.Progressive symptosm [**4-7**] with
epidural abscess
DISEASE
on MRIPast Medical History:Not KnownSocial History:Living with a friend. [**Name (NI) 1351**] no children. On SSI benefits for
asthma
DISEASE
and
neuropathy
DISEASE
. Smokes occasional cigarettes no EtOH.Family History:Parents with DM. Father with [**Name2 (NI) 499**] CA.Physical Exam:Trach in placeAnterior Posterior ICBG wounds clean and dryC5 3/5 strengthC6 3/5 strengthSITIL grossly BUE and BLEC7-S1 No demonstrated motorPertinent Results:[**2168-4-5**] 04:56PM TYPE-ART PO2-95 PCO2-34* PH-7.45 TOTAL CO2-24BASE XS-0[**2168-4-5**] 04:56PM freeCa-1.04*[**2168-4-5**] 08:13AM URINE COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.032[**2168-4-5**] 08:13AM URINE BLOOD-SM NITRITE-NEG PROTEIN-75GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG[**2168-4-5**] 08:13AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONEEPI-Admission Date: [**2174-8-31**] Discharge Date: [**2174-9-2**]Date of Birth: [**2115-1-22**] Sex: FService: NSUPRIMARY DIAGNOSIS: Right middle
cerebral artery aneurysm
DISEASE
.HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 1356**] is a pleasant 59-year-old woman who had previously seen Dr. [**Last Name (STitle) 1132**] in clinic. Shehad previously had an MRI for work-up of questionable
TIA
DISEASE
spells. She describes episodes of lightheadedness
dizziness
DISEASE
as well as
right leg weakness
DISEASE
when climbingstairs. Ultimately she was found to have a right MCA
aneurysm
DISEASE
. She presents to the [**Hospital1 **] [**First Name (Titles) **][**Last Name (Titles) 1357**] coiling of her
aneurysm
DISEASE
and angiogram.PAST MEDICAL HISTORY: Fibromyalgia
dysplasia
DISEASE
.
Gastroesophageal reflux
DISEASE
.
Esophagitis
DISEASE
.
Depression
DISEASE
.
Arthritis
DISEASE
.History of
epistaxis
DISEASE
.PAST SURGICAL HISTORY: Status post [**Last Name (un) 1358**] fundoplication in[**2162**].Status post cholecystectomy.Status post hysterectomy.Status post varicose vein ligation.Status post left knee surgery.MEDICATIONS AT HOME:1. Nicotine 21 mg
TD
DISEASE
qd.2. Zofran.3. Colace.4. Nortriptyline.5. Trazodone.COURSE IN HOSPITAL: The patient was admitted for [**Year (4 digits) 1357**]coiling of right MCA aneurysm. She was taken to theoperating room on [**2174-8-31**]. She was placed undergeneral anesthesia and intubated. She tolerated theprocedure well with no complications. The angiogram showedright MCA aneurysm confirming the preop diagnosis. Therewas a 4 mm right MCA bifurcation
aneurysm
DISEASE
that was coiledusing GDC and Matrix coils. She tolerated the procedure wellwithout complications. She was extubated and then brought tothe recovery room.Postoperatively she remained afebrile with stable vitalsigns. She was following all commands and doing well. Shehad some slight weakness on the left leg. She received 3days of aspirin. The left leg was not in the cerebral territorythat was treated. Accordingly a spinal MRI was obtained whichwas negative.Her postoperative left leg weakness resolved by postop day2. She continued to have gradual improvement until fullrecovery was obtained. Her course in the hospital otherwiseremained uneventful. She remained afebrile with stable vitalsigns. She was transferred out of the unit on postoperativeday 1. She was alert and oriented throughout. She had equaland symmetric pupils. She had a symmetric face with full
extraocular movements
DISEASE
. Her tongue was midline. She had nodrift. She had full grips. She had no
hematoma
DISEASE
. She hadgood distal pulses.Her lines were removed when she was transferred to the floor.She was ambulating independently. Given her left lowerextremity weakness she was planned for a screening MRI ofthe lumbar spine as well as
cervical and thoracic sagittal
DISEASE
images.The patient was currently stable for discharge home. She wasdoing well and tolerating good PO intake. She had beenambulating independently. She had been voiding independentlywithout difficulty. She had been asked to call Dr [**Last Name (STitle) 1132**] in 1-2 weeks. She was continued on her preop medication. [**Name6 (MD) **] [**Last Name (NamePattern4) 1359**] [**MD Number(1) 1360**]Dictated By:[**Last Name (NamePattern1) 1361**]MEDQUIST36D: [**2174-9-2**] 09:49:13T: [**2174-9-2**] 10:30:55Job#: [**Job Number 1362**]Admission Date: [**2197-11-27**] Discharge Date: [**2197-12-1**]Date of Birth: [**2130-8-26**] Sex: MService: MEDICINE
Allergies
DISEASE
:Horse Blood Extract / Bactrim Ds / Adhesive Tape / Sulfa(Sulfonamides)Attending:[**First Name3 (LF) 1363**]Chief Complaint:
Somnolence
DISEASE
.Major Surgical or Invasive Procedure:None.History of Present Illness:This is a 67 y.o male with
bladder cancer
DISEASE
with large pelvicmasses recent chemo tue (taxol gemzar) now presenting withn/v/d/ new afib with RVR metastatic disease. Pt is HD m/w/f.Pt denies
pain
DISEASE
but is unable to report other ROS. States he'stired..In the [**Name (NI) **] pt at first refused IV got EJ removed it ananother was placed. Pt s/p 3L IVF. HR 100-170's not given anynodal agents for rate control. PT found to be
neutropenic
DISEASE
.RUQ-new liver masses/sacral/iliac R.sided hydroureter hasneobladder. Pt given vanco cefepime flagyl. Somnolent head CTnegative. Tmax 100.2.Past Medical History:CAD
HTN
DISEASE
Hyperlipidemia
DISEASE
ESRD
DISEASE
on
HD
DISEASE
Bladder Cancer
DISEASE
in [**2181**]
Depression
DISEASE
Restless
DISEASE
Leg SyndromeSocial History:Patient lives at home with girlfriendAdmission Date: [**2119-1-17**] Discharge Date: [**2119-3-31**]Date of Birth: [**2073-3-6**] Sex: MService: SURGERY
Allergies
DISEASE
:Penicillins / Zofran / Toradol / Phenobarbital / Trazodone /Compazine / OxycodoneAttending:[**First Name3 (LF) 695**]Chief Complaint:
encephalopathy
DISEASE
Major Surgical or Invasive Procedure:Blood transfusionParacentesis x2 ([**1-17**] [**1-23**])[**2119-3-14**] liver transplantHistory of Present Illness:45 y/o male with
ESLD
DISEASE
from HCV
HBC
DISEASE
and EtOH who had a TIPSdone on [**2119-1-5**] who presented to the OSH yesterday with alteredmental status. The patient was treated with lactulose at the OSHwith some improvement in his encelpalopathy. There was concernthat there was a problem with the TIPS and he was transferred to[**Hospital1 18**] for further workup.Denied
chest pain shortness of breath fevers chills
DISEASE
. Hereports
abdominal pain
DISEASE
slightly worse than his baseline. No
melena
DISEASE
or BRBPR..Labs at the OSH significant for
AST/ALT
DISEASE
186/124 TB 12 DB 5Ammonia 330 Na 132.Past Medical History:# L4L5S1 fusion#
Decompensated liver cirrhosis
DISEASE
[**1-28**] to HCV HBC and alcohol c/b
encephalopathy
DISEASE
and
ascites
DISEASE
# Chronic
pancreatitis
DISEASE
# Non
bleeding
DISEASE
grade 2
esophageal varices
DISEASE
in [**4-3**]# GERD-Barrett's esophagus#
COPD
DISEASE
# s/p incarcerated
umbilical hernia
DISEASE
repair [**11-3**] recentadmission on [**2118-12-26**] to [**2118-12-30**] for concern for
cellulitis
DISEASE
around his surgical incision started on clindamycin then vancthen bactrim for a total course of 7 days#OLT [**2119-3-14**]Social History:Married but separated has 3 children. Lives with roommates -limited support. Smokes a pack every 3 days. Quit cocaine andheroine in [**2114**]. Quit EtOH in [**2101**].Family History:Family Hx: No known family history of
hepatitis
DISEASE
or liverdiseasePhysical Exam:VS: 97.5 95/69 90 12 93%RAGen: awake oriented x 2 (able to state month and year statedhe was at BAdmission Date: [**2103-3-7**] Discharge Date: [**2103-3-13**]Service: SURGERY
Allergies
DISEASE
:Codeine / Aspirin / Ibuprofen / Lipitor / CrestorAttending:[**First Name3 (LF) 1390**]Chief Complaint:fall down stairs
syncope
DISEASE
Major Surgical or Invasive Procedure:
Paravertebral block
DISEASE
by
Acute Pain
DISEASE
ServiceHistory of Present Illness:This is a [**Age over 90 **] y/o F with h/o previous C7 vertebral bodycompression fx last year after a
syncopal
DISEASE
event whiledefecating who presents to [**Hospital1 18**] ED after falling down flightof stairs today. Pt was carrying laundry up a flight of stairsand fell when she had a
syncopal
DISEASE
event. Pt aroused at bottom ofstairs and called for help. At presentation she complained ofright sided back
pain
DISEASE
. She had
head c-spine
DISEASE
and torso CT scanwhich showed multiple right sided rib
fractures
DISEASE
. Pt does have
chronic neck pain
DISEASE
after compression fx last year. She wears a
neck brace
DISEASE
as needed at night for comfort. She currently denies
neck pain headache abdominal pain
DISEASE
or distension andadditionally denies any
chest pain
DISEASE
or SOB or
palpitations
DISEASE
priorto the fall.Past Medical History:PMH:1. A-fib2. Type II DM3. Hx of PE 20 yrs ago4.
Hyperlipidemia
DISEASE
5.
Osteoporosis
DISEASE
6.
Osteoarthritis
DISEASE
7.
Anxiety
DISEASE
8. C7 compression
fracture
DISEASE
s/p fall
PSH
DISEASE
: NoneSocial History:Patient lives at home engages in water aerobics everydaydenies use of tobacco alcohol or IV drug useFamily History:Father died from MI at age 50Brother died from MI at age 37Physical Exam:At dischargeVS: Afebrile VSS96.2 87 158/82 16 98%2L
Constitutional
DISEASE
: Well appearing no acute distressNeck: No massesCV: RRR no murmurs.Resp: CTAB no wheezes or crackles IS 300. Admission Date: [**2102-10-1**] Discharge Date: [**2102-10-3**]Date of Birth: [**2019-8-6**] Sex: MService: MEDICINE
Allergies
DISEASE
:Penicillins / QuinolonesAttending:[**Doctor First Name 1402**]Chief Complaint:
Syncope
DISEASE
Major Surgical or Invasive Procedure:[**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] pacemaker placementHistory of Present Illness:83 yo male with history of
hyperlipidema hypertension
DISEASE
bifascicular block
DISEASE
on previous EKG presented to the ED with
syncope
DISEASE
. The patient was feeling lightheaded this evening. Hecalled his daughter to discuss his symptoms. While he was onthe phone the line went dead for approx 3min. He reports helost consciousness during that time. His daughter called EMS.He denied falling during the episode of LOC. When EMS arrivedhe was found to be in complete
heart block
DISEASE
with a ventricularrate in the 20s. He was given atropine en route to the ED..In the ED initial vitals were T99.0 HR 30 BP 140/60 RR18 o2100% on NRB. He was found to be in third degree
heart block
DISEASE
with a continued ventricular rate in the 30s. He was givenatropine again. He sustained a brief episode of
asystole
DISEASE
and atemporary pacer wire was placed. He had appropriate capture andwas paced at a rate of 80bpm. He was intubated for airwayprotection given fentanyl and midazolam for sedation thenchanged to propofol prior to transfer..Unable to obtain review of systems secondary to sedation.Past Medical History:1. CARDIAC RISK FACTORS: (Admission Date: [**2103-6-19**] Discharge Date: [**2103-6-24**]Date of Birth: [**2019-8-6**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Penicillins / QuinolonesAttending:[**First Name3 (LF) 1406**]Chief Complaint:
Dyspnea
DISEASE
on exertionMajor Surgical or Invasive Procedure:[**2103-6-19**] Coronary bypass grafting times 4(left internal mammaryartery to left anterior descending artery reverse saphenousvein graft to right coronary arterysequential reverse saphenousvein graft to first and second obtuse marginal arteries).Permanent left ventricular epicardial lead placementHistory of Present Illness:This 83 year old white male with complaints of
dyspnea
DISEASE
onexertion and abnormal stress echo was referred for cardiaccatheterization. This revealed severe
coronary artery disease
DISEASE
and he was referred for surgical intervention.Past Medical History:
Hypertension
DISEASE
Hyperlipidemia
DISEASE
s/p St. [**Male First Name (un) 923**] PPM for
CHB
DISEASE
[**9-15**]
Arthritis
DISEASE
Sleep apnea
DISEASE
noted after administration of narcotics
Diverticulitis
DISEASE
s/p Left hemicolectomy [**5-/2102**]s/p Back surgery [**2101**]s/p Appendectomys/p TonsillectomySocial History:Race:CaucasianLast Dental Exam:Lives with:wifeOccupation:RetiredTobacco:quit 23 years ago smoked x 50 yearsETOH:[**12-9**] pint of hard alcohol a dayFamily History:noncontributoryPhysical Exam:admission:Pulse:70 Resp:13 O2 sat:97%
RA
DISEASE
B/P Right:156/662 Left:160/64Height:5'1Admission Date: [**2103-7-18**] Discharge Date: [**2103-7-31**]Date of Birth: [**2019-8-6**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Penicillins / QuinolonesAttending:[**First Name3 (LF) 1406**]Chief Complaint:Sternal drainageMajor Surgical or Invasive Procedure:[**2103-7-18**] Sternal debridement with placement of VAC dressing.[**2103-7-23**] Removal of infected epicardial pacing leads. Closure ofthe sternal wound dehiscence with four Synthes plates bilateralpectoralis musculocutaneous advancement flap.History of Present Illness:83-year-old male who underwent coronary artery bypass graftingalong with placement of epicardial pacing wires on [**2103-6-19**].He had been doing fairly well until 3 or 4 days prior toadmission when he began having some drainage from his sternalincision. Upon examination on the day of admission he hadpurulent drainage from the sternal incision and he alsocommented that he noted a sternal click recently. Based uponclinical findings he was admitted for sternal exploration.Past Medical History:Coronary Artery Disease
Hypertension
DISEASE
Hyperlipidemia
DISEASE
s/p St. [**Male First Name (un) 923**] PPM for
CHB
DISEASE
[**9-15**]
Arthritis
DISEASE
Sleep apnea
DISEASE
noted after administration of narcotics
Diverticulitis
DISEASE
s/p Left hemicolectomy [**5-/2102**]s/p Back surgery [**2101**]s/p Appendectomys/p TonsillectomySocial History:Lives with: WifeOccupation: RetiredTobacco: Quit 23 years ago smoked x 50 yearsETOH: [**12-9**] pint of hard alcohol per dayFamily History:NoncontributoryPhysical Exam:HR 83 B/P R 89/49 L
87/52
DISEASE
RR 16
RA
DISEASE
sat 98%General:having
pain
DISEASE
in neck and shoulders traveling down leftbackCardiac: RRR [x] Irregular [] Murmur-noneChest: Lungs clear bilateral [x]Abdomen: Soft [x] Nontender [x] Nondistended [x]Extremities: Warm [x] Well perfused [x]Edema: Right-none Left-noneSternal incision:frank pus draining with
erythema
DISEASE
afebrile
erythema
DISEASE
no[] yes[x]
drainage no[] yes[x]
well approximated yes [x] no []
sternal click no[x] yes[]
EVH site: RLE [] LLE [x]
erythema no[x] yes[]
drainage no[x] yes[]
Pertinent Results:[**2103-7-18**] WBC-15.4*# RBC-3.51* Hgb-10.9* Hct-32.8* Plt Ct-239#[**2103-7-18**] PT-13.2 PTT-34.8 INR(PT)-1.1[**2103-7-18**] UreaN-72* Creat-3.5*# Na-133 K-5.3* Cl-99 HCO3-22AnGap-17[**2103-7-31**] 05:00AM BLOOD WBC-10.8 RBC-2.81* Hgb-8.5* Hct-26.2*MCV-93 MCH-30.1 MCHC-32.3 RDW-16.4* Plt Ct-704*[**2103-7-31**] 05:00AM BLOOD Plt Ct-704*[**2103-7-31**] 05:00AM BLOOD PT-14.7* INR(PT)-1.3*[**2103-7-31**] 05:00AM BLOOD UreaN-49* Creat-1.1 Na-139 K-4.8 Cl-107[**2103-7-29**] 05:38AM BLOOD Glucose-75 UreaN-44* Creat-1.5* Na-142K-3.5 Cl-110* HCO3-23 AnGap-13[**2103-7-23**] 10:00 am FOREIGN BODY PACING WIRES. **FINAL REPORT [**2103-7-26**]** WOUND CULTURE (Final [**2103-7-26**]): STAPH AUREUS
COAG
DISEASE
Admission Date: [**2103-8-7**] Discharge Date: [**2103-8-24**]Date of Birth: [**2019-8-6**] Sex: MService: MEDICINE
Allergies
DISEASE
:Penicillins / Quinolones / CefazolinAttending:[**First Name3 (LF) 905**]Chief Complaint:Acute Hypercarbic Respiratory DistressMajor Surgical or Invasive Procedure:Bilateral thoracentesesS/p removal of chest wall drainHistory of Present Illness:Mr. [**Known lastname 14**] is an 84 year old gentleman with a PMH significantfor recent CAD s/p CABG c/b sternal wound
infection
DISEASE
onantibiotics and
CHB
DISEASE
s/p PPM admitted for a lower extremity
rash
DISEASE
concerning for
vasculitis
DISEASE
and
acute renal failure
DISEASE
. The patientunderwent CABG in [**6-16**] and was re-admitted to [**Hospital1 18**] on [**2103-7-18**]for sternal wound exploration with a drain placed with culturesspeciated as MSSA. At that time he was discharged on cefazolinwith the plan for a prolonged 8 weeks of antimicrobial therapy.On [**8-6**] the ID service was contact[**Name (NI) **] as the patient haddeveloped a
rash
DISEASE
over his lower extremities concerning for a
drug rash
DISEASE
by his physician at rehab. At that time given that hehas a history of an unknown PCN reaction he was converted tovancomycin. Today he presented to the [**Hospital 18**] [**Hospital **] clinic and wasfound to have a
rash
DISEASE
concerning for
vasculitis
DISEASE
and
ARF
DISEASE
with acreatinine of 2 and a serum potassium of 5.7. He was thenreferred to the ED for futher management..In the [**Hospital1 18**] ED initial VS 97.7 60 133/48 20 95%RA. ECG wasnegative for peaked T waves the patient received 30 mgkayexalate had a negative CXR and was admitted to Medicine forfurther management. On ROS the patient reports that he hasbeen feeling increasingly fatigued over the past week withdecreased PO intake but denies any f/c/s n/v/d abd
pain
DISEASE
HA
palpitations
DISEASE
. He is does not know when his
rash
DISEASE
developed..On the floor pt Cr 2.0--Admission Date: [**2131-7-5**] Discharge Date: [**2131-7-24**]Date of Birth: [**2060-12-25**] Sex: MService: SURGERY
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 1481**]Chief Complaint:New diagnosis
Colon Cancer
DISEASE
Major Surgical or Invasive Procedure:[**2131-7-11**]: ERCP with sphincterotomy[**2131-7-16**]: laparoscopic right colectomyHistory of Present Illness:Mr. [**Known lastname 2302**] is a 70 y.o. male with hx of
Crohn's disease
DISEASE
afibdilated CMP h/o PE who presents after recent discharge due tocolon biopsies found positive for
Colon Cancer
DISEASE
. Pt recentadmission was for
bloody stools
DISEASE
and significantly elevated INR.During this admission he had colonoscopy with multiple biopsies. He was discharged in stable condition without any
IBD
DISEASE
meds andwithout anticoagulation. He was called by PCP and told to comeback due to positive colon biopsy and need for furtherstaging/workup. Pt denies any grossly bloody stools at homehas not been taking any meds and has been tolerating po wellwith minimal rectal
pain
DISEASE
.Past Medical History:1.
Crohn's
DISEASE
dz found in [**2125**] on colonoscopy for
anal fissure
DISEASE
positive [**Doctor First Name **] been treated with Remicade2.
Rheumatoid arthritis
DISEASE
3.
HTN
DISEASE
4. hx of renal calculus5. s/p appendectomy6. s/p TURP7. s/p cholecystectomy8. Recent pulmonary embolism- on coumadin since [**2-12**]9.
LVH LV enlargement apical LV aneurysm
DISEASE
with
LV thrombus
DISEASE
EF25%10.
Chronic left knee pain
DISEASE
s/p meniscectomy synovectomy anddebridement of left knee [**2123**]11. Recent
gallstone pancreatitis
DISEASE
[**2-12**]12.
Afib
DISEASE
- [**2-12**] rate controlled on atenololSocial History:Married for 46 years and lives with wife. 3 children who alllive in area. No tobocco h/o occasional ETOH stopped drinkingin [**11-13**] denies h/o ETOH abuse. No illicit drugs.Family History:Father died at 62 from MIMother died at 52 of
cirrhosis
DISEASE
No
cancer
DISEASE
or
diabetes
DISEASE
to patient's knowledgeNo history of
clotting disorders
DISEASE
Physical Exam:T-96.8 BP-140/70 P-96 RR-20 Sats-95% on
RA
DISEASE
Gen: NAD comfortableHEENT: NCAT EOMI MMM oropharynxCV: irreg/irreg no m/r/g no JVDRESP: CTAB no w/r/cracklesABD: soft/NT/ND/NABSEXTR: no c/c/edema Admission Date: [**2103-8-30**] Discharge Date: [**2103-9-13**]Date of Birth: [**2019-8-6**] Sex: MService: MEDICINE
Allergies
DISEASE
:Penicillins / Quinolones / CefazolinAttending:[**First Name3 (LF) 425**]Chief Complaint:
Dyspnea
DISEASE
Major Surgical or Invasive Procedure:CVVHHemodialysisTunneled HD catheter placementHistory of Present Illness:84 yo m hx of
CHF
DISEASE
EF of 40% who was transfered form rehab due toworsening of SOB and
ARF
DISEASE
. He was recetly admitted from[**Date range (1) 1424**] and discharge to rehab. He was on lasix 80mg [**Hospital1 **] then2 days ago lasix was adjusted to 80mg AM and 40mg PM. Per rehabhis Cr has been trendeding up and his dypsnea has beenworsening. At discharge his Cr was 0.9 then 1.1 and now 2.2today. UO has been decreased per pt. Wt gains of 2 lbs over lastfew days..During his last hopsitalization he was treated for a sternalwound
infection
DISEASE
from his CABG on [**6-16**]. On [**7-23**] he had adebridement and wound closer with pacer lead removal on [**7-23**].Epicardial leads were paritally removed. Old PPM remained inplace. He also had a flap closure. Culture of his infecitonshowed MSSA. He developed
AIN
DISEASE
so his antibiotics were changedto vancomycin. He will be on lifelong suppresive therapy afterhis regiment of IV therapy. Hardware in the sternum is in place.His stay was complicated by
CHF
DISEASE
and
ARF
DISEASE
from diuresis laterthis improved to a Cr of 0.9 and he was sent to rehab..On review of systems he denies any prior history of
stroke
DISEASE
TIA
DISEASE
deep
venous thrombosis pulmonary embolism bleeding
DISEASE
at thetime of surgery
myalgias cough hemoptysis
DISEASE
black stools orred stools. Denies recent
fevers chills
DISEASE
or
rigors
DISEASE
. All of theother review of systems were negative..Cardiac review of systems is notable for absence of
chest pain
DISEASE
palpitations syncope
DISEASE
or
presyncope
DISEASE
..In the ED initial vitals were 96.8 67 128/58 20 94% 3L NC. Ptwas given 250mg IVF over 2 hours. Pt's oxygen was increased to4L. On transfer temp 97.9 67 120/45 18 96% 4 liters. CXR withpulm
edema
DISEASE
. Pt admitted to [**Hospital Unit Name 196**]..Past Medical History:-Coronary
Artery Disease
DISEASE
s/p CABG (see below)-Hypertension-Hyperlipidemia-s/p St. [**Male First Name (un) 923**] PPM for Third degree
heart block
DISEASE
[**9-15**]-Arthritis-Sleep
apnea
DISEASE
noted after administration of narcotics-Diverticulitis s/p Left hemicolectomy [**5-/2102**]-s/p Back surgery [**2101**]-s/p Appendectomy-s/p Tonsillectomy-[**2103-7-23**] Sternal debridement closure of the sternal wounddehiscence with four Synthes plates bilateral pectoralismusculocutaneous advancement flap.-ARF due to questionable
AIN
DISEASE
due to cephalosporin orhemodynamically mediated
ARF
DISEASE
in [**2103-6-14**]Social History:-Tobacco history: quit 25 yo ago-ETOH: 1 pint a day until CABG in [**6-16**]-Illicit drugs: noneLived with wife before going to rehab now using a walkerFamily History:NoncontributoryPhysical Exam:GENERAL: Some
tachypea
DISEASE
with talking otherwise NAD. Oriented x3.HEENT: NCAT. Sclera anicteric. PERRL EOMI. Conjunctiva werepink no pallor or
cyanosis
DISEASE
of the oral mucosa. No xanthalesma.NECK: Supple with JVP at his chin while sitting at 45 degreesCARDIAC: Difficult to hear cardiac sounds no murmur sternalwound dressing in place small drainageLUNGS: Resp were slightly
labored pursed lip breathing
DISEASE
able tospeak full sentences no accessory muscle use. soft breathsounds crackles half way up.ABDOMEN: Soft NTND. No HSM or
tenderness
DISEASE
. No
abdominial bruits
DISEASE
.EXTREMITIES: No c/c. 2Admission Date: [**2139-2-4**] Discharge Date: [**2139-2-5**]Date of Birth: [**2078-10-16**] Sex: MService: MEDICINE
Allergies
DISEASE
:DiltiazemAttending:[**First Name3 (LF) 1436**]Chief Complaint:Epigastric pressureMajor Surgical or Invasive Procedure:Cardiac catheterization with stent placed in the Left anteriordescending artery.History of Present Illness:60 M with PMH
HTN
DISEASE
GERD presents with epigastric pressure x 2weeks.
Pain
DISEASE
feels different from GERD pressure-like Admission Date: [**2169-12-30**] Discharge Date:Date of Birth: [**2136-10-31**] Sex: FService: MICUHISTORY OF PRESENT ILLNESS: This is a 33-year-old femalewith a history of
obesity
DISEASE
developmental delay
seizure
DISEASE
disorder depression
DISEASE
and
ventricular septal defect
DISEASE
whopresented with a chief
complaint
DISEASE
of
shortness of breath
DISEASE
tothe [**Hospital1 69**] Emergency Departmenton [**12-30**] after being initially evaluated at [**Hospital3 1442**] Hospital.The patient's symptoms began on [**12-25**] with five days of
cough
DISEASE
temperatures to 101 Fahrenheit shortness of breathand
wheezing
DISEASE
. She went to her primary care physician threedays prior to admission where the temperature was measured at102.2 Fahrenheit and after chest x-ray was negative forinfiltrate she was diagnosed with
bronchitis
DISEASE
and treated withBactrim-DS. She took this for three days but on the day ofadmission the patient was found a home health aide to beincreasingly short of breath and the patient was taken to[**Hospital3 1443**] Hospital where she was satting 92% on 4liters nasal cannula. A chest x-ray showed right lower lobeinfiltrate. The patient was given 125 mg of Solu-Medrolnebulizers ceftriaxone 1 g and transferred to the [**Hospital1 1444**] where she was admitted to theMedical Intensive Care Unit.There the patient was found to be 87% on 4 liters nasalcannula which improved to 93% on 100% face mask. Thepatient's saturations fell to 90% on 100% face mask and BiPAP14/4 was tried. However the patient did not tolerate theBiPAP well despite the fact that the saturations came back toapproximately 95%.REVIEW OF SYSTEMS: On review of systems the patient has nohistory of
asthma
DISEASE
but is a heavy smoker at two to three packsper day for many years. Her membranous ventricular septaldefect was diagnosed on cardiac echocardiogram performed in[**2164**].PAST MEDICAL HISTORY:1. Obesity.2. Developmental delay.3. Seizure disorder status post motor vehicle accident.4. Depression.5.
Ventricular septal defect
DISEASE
.6.
Auditory hallucinations
DISEASE
.7. Melanoma on chest status post excision.ALLERGIES: RISPERIDONE causing
nausea
DISEASE
.MEDICATIONS ON ADMISSION: Outpatient medications includeColace 100 mg p.o. b.i.d. Dilantin 300 mg p.o. q.a.m. and400 mg p.o. q.p.m. Lactase 3 tablets p.o. t.i.d. with mealslorazepam 0.5 mg p.o. t.i.d. p.r.n. perphenazine 4 mg p.o.t.i.d. venlafaxine 150 mg p.o. q.d. Zyprexa 10 mg p.o.t.i.d. Bactrim-DS since [**12-27**] Senna.SOCIAL HISTORY: A two to three pack per day smoker. Livesalone with home health services and advocate.FAMILY HISTORY:
Breast cancer
DISEASE
.PHYSICAL EXAMINATION ON PRESENTATION: Temperature 99.2Fahrenheit heart rate 110 blood pressure 140s/50srespirations 28 to 36 oxygen saturation 93% on 100% facemask. In general alert lying in bed obese in moderate
respiratory distress
DISEASE
. Head ears nose eyes and throatrevealed mucous membranes were moist. No
lymphadenopathy
DISEASE
.Heart was tachycardic but regular. No murmurs rubs orgallops. Pulmonary revealed diffuse rhonchi right greaterthan left prolonged expiratory phase with
wheezing
DISEASE
diffusely. Abdomen was soft nontender and nondistendedwith normal active bowel sounds. Extremities had no
edema
DISEASE
no palpable cords 2Admission Date: [**2141-11-9**] Discharge Date: [**2141-11-20**]Service: VascularCHIEF COMPLAINT:
Chest pain
DISEASE
. Patient was initiallyevaluated at [**Hospital 1474**] Hospital and transferred here forfurther evaluation and treatment. Initial enzymes showed atotal CPK of 4120 CK MB 20 and troponin of 17.4.PAST MEDICAL HISTORY: Coronary
artery disease
DISEASE
status postcath in [**2131**] showing ejection fraction of 56% withanterolateral apical akinesis. The
RCA
DISEASE
is 80% obstructed.The marginal branch of the RCA was 40% obstructed withdiffuse disease. The mid LAD was 95% diagonal I was 60%.The patient underwent angioplasty of the LAD. Patient wasnoted to have mild mitral regurg. A stress test done at thattime showed dilated left ventricle with fixed defects andanterolateral septal wall with high grade
EAE
DISEASE
and equivocalchanges. Previous MI was 5 years prior to 92. History of
peptic ulcer disease
DISEASE
. No previous surgeries no known drug
allergies
DISEASE
.MEDICATIONS: On transfer to our institution Lopressor 12.5mg q 6 hours Atenolol 25 mg q d Nitro paste 1 inch q 4hours Captopril 17.5 mg.SOCIAL HISTORY: He is married lives in [**Location 1475**] is 66years old is a former smoker of 40 pack years no alcoholsemi retired and helps in a welding shop.PHYSICAL EXAMINATION: On admission vital signs 97.5122/91 70 18 O2 saturation 98% on room air. The patientis alert oriented and in no acute distress. HEENT: Showedconstricted pupils secondary to narcotics EOM's intact.Soft palate elevates. No teeth in the lower mandible no
icterus
DISEASE
. Cardiovascular exam was a regular rate and rhythmwith no murmurs rubs or gallops. Neck without
bruits
DISEASE
.Lungs are clear to auscultation bilaterally. Abdomen isunremarkable. Extremities with intact pulses.LABORATORY DATA: On transfer included a CBC with white count6.7 hematocrit 39.1 platelet count 196000. Electrolytessodium 135 potassium 4.6 chloride 100 CO2 77 BUN 11creatinine 0.1 glucose 114 PT and INR were normal PTT werenormal. CK totals were 0 90 and peak to 412 MB were 82 and6 MBI index was 20 troponin was 17.4. Urinalysis wasnegative. EKG showed a normal sinus rhythm with a normalaxis deviation with inverted T's in V4 and V5 which were new.HOSPITAL COURSE: The patient was admitted to the cardiologyservice and was placed in Intensive Care Unit. IV Heparinand Nitroglycerin were begun. Serial CKs were obtained alongwith serial EKG's. Serial total CK's peaked at 533. MBfraction peaked at 9.2. Initial troponin level was greaterthan 50 and after the next 72 hours its level was 1.5.Normal is less than .03. Within the next 24 hours thepatient underwent cardiac catheterization. The patient'sright sided pressures PA was 50/17 right atrial mean was16 pulmonary wedge pressure was 16 left ventricular enddiastolic pressure was 17. Cardiac output was 6.0 index was3.3 EF was 30% with akinetic anterolateral and apex wallsand hypokinetic antero basal wall and normal posterior andbasal wall. The native vessels showed left main trunkdisease of 30% left anterior was proximal 30% and mid 90%left circumflex was mid 50%. Ramus intermedius was 90% whichwas angioplastied and stented and the right coronary showedan osteal lesion of 30%. There was concern of right externaliliac artery dissection. The patient underwent a rightfemoral ultrasound which demonstrated triphasic flow in theright common femoral artery with
plaque
DISEASE
or flap proximal tothe right SFA with
stenosis
DISEASE
and did have episodes of SVG andwas begun on beta blockers. Aspirin and Plavix were continuedpost stenting. The groin was without
bleeding
DISEASE
and he haddistal pulses. Dr. [**Last Name (STitle) **] the cardiologist requested thatvascular be consulted regarding the findings on the rightiliac SFA ultrasound. The patient although study wasabnormal but with intact distal pulses the patient did note72 hours after catheterization onset of right calf and anklefoot
pain
DISEASE
with ambulation. The patient underwent a repeatperipheral arterial catheterization which demonstratedabdominal aorta with no significant disease renal arteriesbilaterally were normal the right lower extremity iliac iswithout critical lesions the previous noted dissection isnot occlusive but the site is still delineated. The commonfemoral is normal the SFA and profunda artery are normalthe popliteals occlude mid vessel and the anterior and tibialwere not well visualized but appear thrombolyticallyoccluded. There was three vessel runoff to the foot. Thecollaterals provide much of the distal flow. The patient was
TPA'd
DISEASE
begun on Heparin and placed in the VICU. The patienthad consequences of a right groin
hematoma
DISEASE
after the secondright groin intervention and angiography which requiredpressure occlusion. The patient underwent on [**11-14**] athrombectomy of the right tibial peroneal trunk and AT arterywith patch angioplasty of the right popliteal artery. Hetolerated the procedure well and was transferred to the VICUfor continued monitoring and care. The patient required aunit of packed cells for hematocrit of 25 post transfusionhematocrit was 35. Total CK was 74. The patient was placedon peri-operative Kefzol and remained in the
VICU
DISEASE
in stablecondition. On [**11-15**] the patient had an episode of
hematemesis
DISEASE
. An NG was placed with 300 cc of bloodaspirated. The patient remained hemodynamically stable.Serial hematocrits were obtained and Plavix and Aspirin wereheld. GI was consulted. The patient underwent upperendoscopy which demonstrated a few non
bleeding
DISEASE
localized
erosions
DISEASE
in the esophagus at the GE junction consistent withNG trauma. There was bilious fluid in the stomach body andantrum. There is no active
bleeding
DISEASE
or coffee ground orbright red blood noted. There were few superficial non
bleeding
DISEASE
2 mm
ulcers
DISEASE
ranging in size from 2 mm to 5 mm in thestomach. The duodenum was normal. Recommendations were tocontinue the Protonix at 40 mg q d discontinue the NG tubefollow serial hematocrits. Please consider the risk/benefitsof Aspirin and Plavix. If Aspirin and Plavix need to becontinued then we will put the patient on a higher dose ofProtonix. The patient experienced episode of
hypertension
DISEASE
overnight on postoperative day #1 requiring adjustments in
hypertensive
DISEASE
medications and transfusion of packed red bloodcells. On postoperative day #3 there were no overnightevents. The patient continued on Protonix IV and Captopriland beta blockers. His hematocrit remained stable at 29.CKs were flat and serial hematocrits remained stable. Thepatient was then begun on Aspirin. Physical therapy saw thepatient and felt that he would be able to be discharged tohome after evaluating ambulation with stairs. The patient'shematocrits remained stable groin remained stable. Thepatient was discharged in stable condition on [**2141-11-20**]. Sheis to follow-up with Dr. [**Last Name (STitle) **] as instructed and see Dr.[**Last Name (STitle) 1476**] in two weeks time.DISCHARGE MEDICATIONS: Include Keflex 500 mg qid times 7days Aspirin 81 mg q d Lopressor 25 mg [**Hospital1 **] hold forsystolic blood pressure less than 120 heart rate less than60 Protonix 40 mg q d Colace 100 mg [**Hospital1 **] Percocet tablets[**12-27**] q 4 hours prn
pain
DISEASE
Plavix 75 mg q d.DISCHARGE DIAGNOSIS:1. Non Q wave MI status post angioplasty of the ramusintermedius with stenting.2. Right groin
hematoma
DISEASE
stabilized.3. Right iliac external artery dissection stabilized.4. Thrombolic
ischemia
DISEASE
of the right leg status postthrombectomy of the anterior tibial and peroneal trunk.5.
Hypertension
DISEASE
controlled.6. GI bleeding stabilized.7.
Blood loss anemia
DISEASE
transfused corrected. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**] M.D. [**MD Number(1) 1478**]Dictated By:[**Last Name (NamePattern1) 1479**]MEDQUIST36D: [**2141-11-19**] 16:01T: [**2141-11-19**] 16:50JOB#: [**Job Number 1480**]Admission Date: [**2200-7-10**] Discharge Date: [**2200-7-15**]Date of Birth: [**2150-10-11**] Sex: FService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1481**]Chief Complaint:
Colitis
DISEASE
with
bleeding
DISEASE
Major Surgical or Invasive Procedure:Right ColectomyHistory of Present Illness:49 yo female who has had
blood loss
DISEASE
over a period of severalmonths and has had abnormal colonoscopies which have shown someareas of stricturing. This has been unusual but is thought mostlikely to be due to
Crohn's disease
DISEASE
. She hasbeen on steroids but still with problems. She presents now witha hematocrit of 20. She is a Jehovah's witness and will notaccept any blood transfusions. After consultation with herGeneral Medical physician and also with the hematology serviceit was thought that it would not be possible to increase herhematocrit significantly prior to operation without at least a 1month delay. It was also thought likely that any improvement iniron therapy would be off-set by continued
bleeding
DISEASE
. The patientand her partner understand the gravity of this situation and theneed for operation under less than optimum circumstances. Thepatient has again expressed her wish that she not be given bloodproducts but she would accept certain other types of fluid. Shepresentsnow for right colectomy.Past Medical History:Neuralgia
Rheumatoid arthritis
DISEASE
Depression
DISEASE
Social History:Patient is Jehovah's witness (okay with FFP plts cryoalbumin and any product that does not have RBC's). Denies ETOHor recreational drug use. Smokes 1 pack per week.Physical Exam:Gen: NADChest: CTA bilaterally no
wheezes rales
DISEASE
or rhonchiCV: RRR no murmurs rubs or gallopsAbd: Admission Date: [**2113-7-25**] Discharge Date: [**2113-7-31**]Date of Birth: [**2030-11-26**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1253**]Chief Complaint:Acute mental status changeMajor Surgical or Invasive Procedure:Embolectomy [**2113-7-27**]History of Present Illness:Pt's a 82 yo F with h/o
HTN
DISEASE
h/o of prox a-fib (not oncoumadin)
mood disorder
DISEASE
on depakote (has had since CVA 4 yrsprior) with prior L inferior division MCA infarct nowpresenting with altered mental status. Pt basically at baselineAA0x2 has been reclusive living alone with
mood disorder
DISEASE
sinceher
stroke
DISEASE
- but has family heavily involved in her care -including ex-husband who visits daily. Pt basically has been ather baseline (which is described as more aggressive - usuallyasking her family to leave within 10-15minutes of being aroundher) but then 3-4 days ago noted being more lethargic - lessaggressive but without any other notable complaints perex-husband who saw pt then (no report of CP F/C HA SOB asbest assessed). Family getting concerned - were thinking wouldbe needing more higher level care placement as pt generallyweaker (no focal weaknesses) - but Sunday started appearing atbaseline again. Pt was seen Monday early and was doing well(has called ex-husband roughly around 2pm and noted again at herbaseline) - however when home aide came by apartment today inthe morning - pt did not respond to door - found lethargic withemesis/stool/urine around her. No further information able tobe obtained related to any events preceding to the evident n/vbowel/stool incontinance.Admission Date: [**2179-3-18**] Discharge Date: [**2179-3-24**]Date of Birth: [**2105-12-17**] Sex: FService: MEDICINE
Allergies
DISEASE
:Heparin AgentsAttending:[**First Name3 (LF) 949**]Chief Complaint:
hypothermia sepsis
DISEASE
Major Surgical or Invasive Procedure:EGDflex sigHistory of Present Illness:73yo F with
PBC decompensated cirrhosis c/b encephalopathy
DISEASE
ascites
DISEASE
and esoph varices who was discharged 2 days prior toadmission with AMS thought to be related to hepatic
encephalopathy
DISEASE
. At that time she was also found to have
hypoglycemia
DISEASE
PNA (tx w/ Azithro) and a
UTI
DISEASE
(tx w/ Bactrim).She was referred from clinic at [**Hospital Unit Name **] with chief
complaint
DISEASE
of BRBPR. She noted 2 painless BM's with BRBPR andblood was noted on rectal exam without
melena
DISEASE
. She denied any CPor SOB but does note feeling weak. She does note some decreasedurine output lately as well as increased LE
edema
DISEASE
and abdominaldistention. She notes
abdominal 'fullness'
DISEASE
for the last fewweeks but denies nausea/vomiting. She notes some
lightheadedness
DISEASE
and
thirst
DISEASE
while in the ED..In the ED she was initially normotensive but was later found tohave SBP's in the 70's (baseline SBP in 90's). She was alsonoted to be hypothermic with core temp of 93.4. Because ofconcern for
sepsis
DISEASE
an IJ was placed and she was placed on
sepsis
DISEASE
protocol. She was given Vanc/CTX/Flagyl and hydrocort and wasalso noted to have worsening renal function with a Cr of 2.1from NL baseline. Because of an initial potassium of 6.9 shewas given D50/insulin/kayexylate. She was admitted to the MICUfor further monitoring.Past Medical History:1. PBC
cirrhosis
DISEASE
x 13 yrs known varices followed by Dr.[**Last Name (STitle) 497**]2.
Liver cirrhosis
DISEASE
3.
Hypothyroidism
DISEASE
4.
Osteopenia
DISEASE
5. Status post cholecystectomy6. History of ankle
fractures
DISEASE
7.
Hypertension
DISEASE
Social History:Tobacco stopped 15 yrs ago 30 pack-yrs no alcohol or drug usemarried with three children. Lives at home with husbandFamily History:No family history of
strokes seizures
DISEASE
. Mother and father diedin 90s.Physical Exam:vitals (ED)- TAdmission Date: [**2179-3-31**] Discharge Date: [**2179-4-15**]Date of Birth: [**2105-12-17**] Sex: FService: MEDICINE
Allergies
DISEASE
:Heparin AgentsAttending:[**First Name3 (LF) 943**]Chief Complaint:
dizziness
DISEASE
x 1 dayMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:73 yo F with h/o
PBC decompensated cirrhosis
DISEASE
c/b
encephalopathy ascites
DISEASE
and esoph varices who presents with c/o
lightheadedness dizziness
DISEASE
x 1 day. Feels weak with decreasedenergy level. Of note recently discharged on [**2179-3-24**] afterhypotensive/hypothermic episode w/ suspected
sepsis
DISEASE
treatedempirically with a course of ceftriaxone flagyl and stress-dosesteroids. No infectious source was identified. Discharged tohome to complete prednisone taper..In ED today found to be
hypotensive
DISEASE
(SBP's in 80's) andhypothermic (31 C rectal temp). EKG w/
bradycardia
DISEASE
to 40's. Plt18. INR 1.5. given rewarming blankets. b/l EJ PIV placed. given3L IVF's followed by peripheral dopa in ED. Recieved empiricsteroids w/ dex for Admission Date: [**2142-5-31**] Discharge Date: [**2142-6-8**]Date of Birth: [**2070-2-24**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1505**]Chief Complaint:
Chest pain dyspnea
DISEASE
on exertionMajor Surgical or Invasive Procedure:[**2142-5-31**] Four Vessel Coronary Artery Bypass Grafting utilizingthe left internal mammary to left anterior descending arterywith vein grafts to ramus intermedius obtuse marginal and PDA.History of Present Illness:This is a 72 year old with known
coronary artery disease
DISEASE
. Overthe last several months he began to experience worsening chest
pain
DISEASE
and
dyspnea
DISEASE
on exertion. He recently underwent stresstestng which was positive for
ischemia
DISEASE
. Stress ECHO in [**Month (only) 216**][**2140**] was notable for an LVEF of 55-60%. Subsequent cardiaccatheterization on [**2142-5-11**] revealed severe three vessel coronary
artery disease
DISEASE
. Based upon the above results he was referredfor coronary surgical intervention.Past Medical History:
Coronary Artery Disease
DISEASE
History of PTCA(ramus) [**2128**]History of
Myocardial Infarction
DISEASE
[**2125**]
Diabetes Mellitus
DISEASE
Type II
Hypertension
DISEASE
Hyperlipidemia
DISEASE
History of
Prostate Cancer
DISEASE
- s/p Radical Prostatectomy
Arthritis
DISEASE
Gout
DISEASE
TonsillectomySocial History:Married with grown children. He is a very active volunteer. Heworked at the Mass Transit Authority prior to retiring/ Socialhistory is significant for the absence of current tobacco usequit in [**2091**]. There is no history of
alcohol abuse
DISEASE
and nocurrent alcohol use.Family History:There is no family history of
premature coronary artery disease
DISEASE
or sudden death. His father had
CHF
DISEASE
in his 80s.Physical Exam:Vitals: BP 167/80 HR 56 RR 18General: well developed male in no acute distressHEENT: oropharynx benignNeck: supple no JVD no
carotid bruits
DISEASE
Heart: regular rate normal s1s2 no murmur or rubLungs: clear bilaterallyAbdomen: soft nontender normoactive bowel soundsExt: warm no
edema
DISEASE
no varicositiesPulses: 2Admission Date: [**2150-6-19**] Discharge Date: [**2150-6-26**]Date of Birth: [**2099-8-8**] Sex: FService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 1515**]Chief Complaint:s/p
Cardiac Arrest
DISEASE
Major Surgical or Invasive Procedure:Endotracheal intubationICD placementHistory of Present Illness:50F with hx of
coronary vasospasm HTN
DISEASE
that presents from an OSHafter having suffered a
cardiac arrest
DISEASE
in the field s/p CPRwith
shock
DISEASE
x1.Of note the pt was admitted to the [**Hospital1 1516**] service at [**Hospital1 18**] from[**Date range (3) 1517**] after a month of increasing chest discomfortconcerning for
coronary ischemia
DISEASE
. While hospitalized she haddynamic ST depressions in V3-V6 during
anginal episodes
DISEASE
andelevated trop to 0.16. At that time workup included both cardiaccath (X2) and CT of the coronary arteries. Cath suggestedisolated bilateral
coronary ostial stenosis
DISEASE
. CTA was withoutevidence of
atherosclerosis
DISEASE
. At the time it was thought the ptsuffered from
cardiac vasospasm
DISEASE
and not CAD. The pt was placedon diltiazem Imdur and amlodipine. The pt followed up incardiology clinic [**5-25**] and at the time was feeling with only 2lesss severe episodes of retrosternal chest pressure [**4-12**] thatoccurred spontaneously without exertion lasting 10 min withcomplete resolution. The pt had been able to participate inaerobic exercise 45 minutes and endorsed 40lbs wt loss while onWeight Watchers program. The pt was last seen by her PCP [**Last Name (NamePattern4) **][**2150-6-8**] Dr. [**Last Name (STitle) 1057**] at which time she was feeling well. At thetime she reported LE
edema
DISEASE
since initiating amlodipine.This morning the pt was bringing her children to school. Familynotes that patient has had increased chest discomfort this weekand using nitroglycerin at work. Her daughter notes
chest pain
DISEASE
this morning which resolved prior to taking her daughter toschool. EMS reports that arrived on scene with bystander CPR inprogress (approx 7:45). Arrest was confirmed. The pt was shockedonce. CPR was continued and on second analysis no
shock
DISEASE
wasadvised. At that time the pt was noted to move Amiodarone 150mgwas loaded and subsequently transferred to an OSH.On arrival to the OSH (hx obtained by [**Hospital 1281**] Hospital EDphysician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1518**] via phone) initial vitals 108/55 HR 147Wt 99.7kg. The pt was intubated (two attempts made). HR rangedfrom 123 to 151 with SBPs 108/55 to 174/74. 140's to 150's.Exam was notable for pt as unresponsive but was reaching for thetube. She did not respond to commandy prior to being intubatedwith Succinylcholine 150mg Versed 4mg Vecuronium 10mg and puton a propofol gtt. No acute EKG changes. Wbc 20. ck/trop neg.CXR/CT of chest shows large aspiration
pneumonia
DISEASE
CT Head/CT
C-spine
DISEASE
unremarkable. The pt was given Ceftiaxone 1gmClindamycin 600mg Azithromycin 500mg. 18G. Small lac to back ofhead- going to get some staples prior to transfer. Vitals priorto transfer were HR 124 117/57.In the CCU the patient is intubated. When propofol is weanedpatient moves all extremities however does not respond tocommands or follow directions.On review of systems unable to be obtained from patient. Familyreports that she was in her usual state of health and went tothe beach this past weekend. Besides
chest pain
DISEASE
episodes notedabove no other symptoms were reported by the patient. Familynotes patient to be a non reporter.Past Medical History:1. CARDIAC RISK FACTORS: (-)Diabetes (-)Dyslipidemia (-)HTN2. CARDIAC HISTORY:-CABG: None.-PERCUTANEOUS CORONARY INTERVENTIONS: None.-PACING/ICD: None.3. OTHER PAST MEDICAL HISTORY:h/o
cholecystitis
DISEASE
s/p cholecystectomySocial History:Works in NICU at [**Hospital1 18**]-Tobacco history: none-ETOH: none-Illicit drugs: noneFamily History:Paternal grandfather with MI at age 50. Father with
hypertension
DISEASE
.Physical Exam:Admission LabsVS: 122/58 95 100%GENERAL: Intubated SedatedHEENT: NCAT. Sclera anicteric. PERRL. Laceration on back of headwith staples in place.NECK: Supple with JVP at base of neck.CARDIAC: PMI located in 5th intercostal space midclavicularline. RR normal S1 S2. No m/r/g. No thrills lifts. No S3 orS4.LUNGS: No
chest wall deformities scoliosis
DISEASE
or
kyphosis
DISEASE
. Respwere unlabored no accessory muscle use. CTAB no crackles
wheezes or rhonchi
DISEASE
.ABDOMEN: Soft obese NTND. No HSM or
tenderness
DISEASE
.EXTREMITIES: No c/c/e.SKIN: No
stasis dermatitis ulcers
DISEASE
scars or
xanthomas
DISEASE
.PULSES:Right: Carotid 2Admission Date: [**2190-2-11**] Discharge Date: [**2190-2-24**]Date of Birth: [**2132-12-15**] Sex: FService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 1257**]Chief Complaint:
Dyspnea
DISEASE
Major Surgical or Invasive Procedure:BronchoscopyHistory of Present Illness:57 yo F with PMHX of
HTN
DISEASE
who presents with
shortness of breath
DISEASE
x7 days worsening over the last 3 days. Patient reports that shehas been feeling weak over the last 3 weeks with anunintentional 10 lb
weight loss
DISEASE
(of note over the last 2 monthsshe has lost 20lbs). 1 week ago she started feeling SOB withexertion and Admission Date: [**2125-4-5**] Discharge Date: [**2125-4-12**]Date of Birth: [**2072-2-15**] Sex: MService: Cardiac SurgeryHISTORY OF PRESENT ILLNESS: This is a 53-year-old gentlemanwho went to see his primary care physician for his yearlyphysical. At that time he reported a 1-year history ofburning substernal
chest pain
DISEASE
with exertion. He underwent anexercise treadmill test which was positive and subsequentlyunderwent cardiac catheterization which showed an ejectionfraction of 55% 90% left main coronary artery 90% proximalleft anterior descending artery 60% to 80% left circumflexand a proximally occluded right coronary artery. The patientwas referred to Dr. [**Last Name (STitle) 1537**] for urgent coronary artery bypassgrafting.PAST MEDICAL HISTORY:1. Hypertension.2. Hypercholesterolemia3.
Gastroesophageal reflux disease
DISEASE
.ALLERGIES: No known drug allergies.MEDICATIONS ON ADMISSION:1. Hydrochlorothiazide 25 mg by mouth once per day.2. Lipitor 40 mg by mouth once per day.3. Zantac 150 mg by mouth twice per day.SOCIAL HISTORY: The patient lives at home with his wife andhis two children. He works in construction. Positivetobacco with half a pack per day for 40 years.BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admittedto [**Hospital1 69**] and taken to theoperating room on [**2125-4-6**] with Dr. [**Last Name (STitle) 1537**] for a coronaryartery bypass graft times three. Left internal mammaryartery to left anterior descending artery saphenous veingraft to obtuse marginal and saphenous vein graft toposterior descending artery. The patient had an intra-aorticballoon pump placed in the Cardiac Catheterization Laboratorydue to his difficult anatomy and that remained during hissurgery.The patient was transferred to the Intensive Care Unit instable condition on a Neo-Synephrine infusion.Postoperatively the patient requried a moderate amount ofvolume resuscitation.Due to his elevated filling pressures and some minorpostoperative electrocardiogram changes a transesophagealechocardiogram was performed at the bedside which showed anormal ejection fraction with no
wall motion abnormalities
DISEASE
.The patient's hemodynamics improved over the next couple ofhours. On postoperative day one the patient was weaned andextubated from mechanical ventilation. The intra-aorticballoon pump was removed without difficulty. TheNeo-Synephrine was weaned to off.On postoperative day two the patient was started onLopressor which he tolerated well. On postoperative daythree the patient's chest tubes were removed withoutdifficulty as well as his pacing wires.On postoperative day four the patient's hematocrit was notedto be down to 21. The patient was not symptomatic and hadstable vital signs. It was discussed with Dr. [**Last Name (STitle) 1537**] and atransfusion was deferred.On postoperative day five the patient continued to ambulatewith Physical Therapy.On postoperative day six the patient's hematocrit was notedto be down to 20.8. The decision was made to transfuse thepatientAdmission Date: [**2160-2-19**] Discharge Date: [**2160-2-24**]Date of Birth: [**2095-10-21**] Sex: MService: EP SERVICECHIEF COMPLAINT: Syncope.HISTORY OF PRESENT ILLNESS: This is a 64-year-old man withan extensive cardiac history including coronary arterydisease status post
myocardial infarction
DISEASE
times two statuspost multiple interventions
congestive heart failure
DISEASE
with anejection fraction less than 20%
ventricular tachycardia
DISEASE
status post AICD placement in [**2157**] who presented to theEmergency Department after
syncopal
DISEASE
episodes and AICD firing.The patient noted three days prior to admission feeling of
palpitations
DISEASE
especially when lying down for bed. On the dayof admission the patient became lightheaded a while bendingdown to tie his shoes and felt some
palpitations
DISEASE
. He thenfelt a
shock
DISEASE
from his ICD. He thereafter awoke on thefloor. Over the course of the day he had three moreepisodes a feeling of
palpitations
DISEASE
and
lightheadedness
DISEASE
followed by a
shock
DISEASE
and then losing consciousness.In the Emergency Department the patient was observed to havean irregular wide complex
tachycardia
DISEASE
consistent with atrial
fibrillation
DISEASE
in the setting of his underlying left bundle
branch block
DISEASE
. While in the Emergency Department hedeveloped transient regular wide complex
tachycardia
DISEASE
toapproximately 170 beats per minute. His ICD fired duringthis rhythm and was subsequently degenerated into a
ventricular fibrillation
DISEASE
prompting the ICD to fire againrecovering the rhythm back to
atrial fibrillation
DISEASE
. Anamiodarone load was begun and the patient appeared tospontaneously convert to sinus rhythm with left bundle branchblock. The ICD settings were increased while the patient wasin the Emergency Department so that the first
shock
DISEASE
administered was increased from 12 to 24 joules. The patientwas admitted to the Coronary Care Unit for continuedintravenous amiodarone loading and further evaluation.PAST MEDICAL HISTORY: Coronary
artery disease
DISEASE
status post
myocardial infarction
DISEASE
in [**2136**] and [**2150**]. He is status postmultiple percutaneous transluminal coronary angioplasty andstents. Last catheterization on [**11/2159**] showed an ejectionfraction of 15% with anterolateral apical and inferiorakinesis. He had 2Admission Date: [**2160-12-25**] Discharge Date: [**2161-1-10**]Date of Birth: [**2095-10-21**] Sex: MService:HISTORY OF PRESENT ILLNESS: This is a 64-year-old man with ahistory of
ischemic dilated cardiomyopathy
DISEASE
who presents withfive days of
shortness of breath
DISEASE
. He developed the
shortness
DISEASE
of breath in the setting of
cough lethargy
DISEASE
and subjective
fevers
DISEASE
. He presents to the Emergency Room where he was foundto be significant dyspneic. Physical examination revealedevidence of
pulmonary edema
DISEASE
and a chest x-ray showedbilateral infiltrates. His oxygen saturation was 86% on roomair. His ABG was 7.54 48 27. He was given supplementaloxygen and 60 mg of IV Lasix with a good response and hisoxygen saturation increased to 90% on three liters. He wasadmitted to the cardiac floor with a diagnosis of a
CHF
DISEASE
exacerbation.About one hour after arriving on the floor about five hoursafter presentation he was found to be acutely hypoxic withan oxygen saturation in the low 80's despite being on 100%non rebreather. EKG showed possible inferior ST elevationsin the setting of a paced left
bundle branch block
DISEASE
. Hecontinued to be hypoxic despite an additional 200 mg IV ofLasix Heparin and a Nitro drip. For this reason he wasemergently intubated and transferred to the CCU.On arrival to the CCU he was noted to have a temperature of103.5. His heart rate was increased and his blood pressurewas low. His urine output dropped off. He was started onDopamine and his Nitro drip was stopped. He was also startedon Vanco Levo and Flagyl. As he defervesced his vitalsigns stabilized and he began to have normal urine outputagain.PAST MEDICAL HISTORY: 1)
Coronary artery disease
DISEASE
status postanterior MI times two in [**2136**] in [**2145**] with an IMI in [**2150**].Cath in [**2160-7-16**] revealed two vessel coronary arterydisease with a left ventricular apical
aneurysm
DISEASE
. 2)
Congestive heart failure
DISEASE
with an EF of 20%. 3) Status postAICD placement for monomorphic
ventricular tachycardia
DISEASE
upgraded in [**2160-2-14**]. 4)
Atrial fibrillation
DISEASE
status postablation in [**2160-2-14**] currently on Amiodarone. 5)
Hypertension
DISEASE
. 6)
Hypercholesterolemia
DISEASE
. 7) Chronic
obstructive pulmonary disease
DISEASE
. 8)
Obstructive sleep apnea
DISEASE
onbi-pap of 15 and 10 at home.MEDICATIONS: Amiodarone 400 mg q day Lasix 120 mg q a.m.Lipitor 20 mg q day Aspirin 81 mg q day Potassium Chloride16 mEq q day Captopril 12.5 mg tid recently decreased from25 mg tid Coreg 18.75 mg [**Hospital1 **] Xanax 0.25 mg tidMultivitamin Vitamin E Coumadin 2.5 mg q day except for 5mg on Tuesday and Saturday Zaroxolyn 2.5 mg po q weekMirapex 0.125 mg q day.ALLERGIES: No known
drug allergies
DISEASE
.SOCIAL HISTORY: Works as a private investigator. Isseparated from his wife. [**Name (NI) **] a 55 pack year history ofsmoking and quit in [**2155**]. Uses alcohol socially. Has nohistory of
drug abuse
DISEASE
.PHYSICAL EXAMINATION: This is a 65-year-old man who wasintubated and sedated with a blood pressure of 93/42 on 5 ofDopamine. Heart rate is 60 and he is satting 100% on 100%FIO2. His HEENT exam is unremarkable. His neck is supplewith bounding carotid pulses. His chest is clearanterolaterally. His heart is regular with no murmurs rubsor gallops. His abdomen is benign. His extremities arewithout
edema
DISEASE
with 2Admission Date: [**2130-8-17**] Discharge Date: [**2130-8-21**]Date of Birth: [**2079-11-23**] Sex: FService: [**Doctor First Name 147**]
Allergies
DISEASE
:Penicillins / BactrimAttending:[**First Name3 (LF) 1556**]Chief Complaint:
Morbid obesity
DISEASE
Major Surgical or Invasive Procedure:1. Laparoscopic Roux en Y gastric bypass. ([**8-17**])2. Laparoscopic cholecystectomy. ([**8-17**])3. Takeback for Laparoscopic abdominal exploration. ([**8-18**])History of Present Illness:Mrs. [**Known lastname 1557**] is a 50 year oldwoman with longstanding morbid
obesity
DISEASE
refractory to nonoperative attempts at
weight loss
DISEASE
. She has a preoperativeweight of 230.7 pounds a height of 63 inches and a body massindex of 40.9. She was evaluated by a multi-disciplinarybariatric team anddeemed a suitable candidate for gastric bypass in accordancewith the NationalInstitute of Health Consensus Statement.Past Medical History:She suffers from associated comorbiditiesincluding
hypertension
DISEASE
non insulin dependent
diabetes
DISEASE
mellitus dyslipidemia cardiac disease
DISEASE
consisting of
diastolic dysfunction gastroesophageal reflux
DISEASE
non alcoholic
hepatitis cholelithiasis
DISEASE
urinary
stress incontinence
DISEASE
osteoarthritis
DISEASE
of the lower extremities and
low back pain
DISEASE
.Social History:Socially she does not smoke although she has a 10-pack-yearhistory. She does not use drugs or drink excessive amounts ofalcohol. She is a nurse with a doctor at education and employedat the [**State 1558**] in [**Hospital1 1559**]. She is marriedand lives with her husband and two children.Family History:Her family history is noteworthy for
heart disease arthritis
DISEASE
obesity
DISEASE
and
diabetes
DISEASE
.Physical Exam:On examination her recorded blood pressure is 142/82 with apulse of 82. She is alert and oriented and in no acute distress.Pupils are equal round and reactive to light. Sclerae areanicteric. Oropharynx is without lesions. There are no looseteeth. Neck is supple without
jugular venous distention bruits
DISEASE
lymphadenopathy
DISEASE
thyromegaly or nodules. Trachea is in midline.Lungs are clear to auscultation bilaterally. Heart is regularwith no murmurs rubs or gallops. Abdomen is obese softnontender and nondistended. There is no
organomegaly
DISEASE
or masses.There are no
hernias
DISEASE
. Extremities have
trace edema
DISEASE
bilaterallywith no evidence of
venous stasis
DISEASE
or varices. There is no spineor
flank tenderness
DISEASE
. Neurologically cranial nerves II throughXII are intact and otherwise nonfocal.Pertinent Results:[**2130-8-17**] 10:14PM WBC-11.2*# RBC-4.18* HGB-11.7* HCT-35.0*MCV-84 MCH-27.9 MCHC-33.4 RDW-13.4[**2130-8-17**] 10:14PM NEUTS-86.5* BANDS-0 LYMPHS-10.2* MONOS-2.9EOS-0.3 BASOS-0.1[**2130-8-17**] 10:14PM GLUCOSE-167* UREA N-10 CREAT-0.6 SODIUM-139POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13Brief Hospital Course:Patient tolerated lap RYGBP and CCY and was transferred to PACU.On night of POD0 patient was nauseous refractory to ZofranCompazine and Phenergan. Subsequently her PCA was changed fromMSO4 to
Dilaudid
DISEASE
and she was provided a Scopolamine patch. Laterin the night patient desat'ed to 79% on
RA
DISEASE
with continued
nausea
DISEASE
. In AM of POD1 patient was transferred to T-SICU for
hypoxia
DISEASE
. CTA of chest was done and demonstrated no PE butevidence of bilateral consolidation. CT abdomen demonstrated noobvious leak. She was started on IV antibiotics for questionaspiration
pneumonia
DISEASE
. After being seen by Dr. [**Last Name (STitle) **] in SICUteam decided to take patient back to OR for laparoscopicexploration to rule out leak. No leak was found in OR. Patienttolerated procedure well and was back in PACU. She wastransferred to floor without incident. Post-op course wasunremarkable thereafter. On [**8-19**] she was started on Stage I andtransitioned to Stage II later in the day. On day of dischargepatient did well on Stage III with good
pain
DISEASE
control on oralRoxicet. Patient was sent home with oral antibiotics for 10days.Discharge Medications:1. Roxicet 5-325 mg/5 mL Solution Sig: [**1-20**] teaspoons PO every4-6 hours as needed for
pain
DISEASE
.Disp:*250 ml* Refills:*0*2. Zantac 15 mg/mL Syrup Sig: Ten (10) ml PO twice a day for 1months.Disp:*qs * Refills:*0*3. Multi-Vitamins W/Iron Tablet Chewable Sig: One (1)Tablet Chewable PO twice a day.Disp:*60 Tablet Chewable(s)* Refills:*2*4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every24 hours) for 10 days: Needs 10 total days of levo & flagyl.Disp:*10 Tablet(s)* Refills:*0*5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3times a day) for 10 days: Needs 10 total days of levo & flagyl.Disp:*30 Tablet(s)* Refills:*0*Discharge Disposition:HomeDischarge Diagnosis:Morbid
obesity
DISEASE
s/p laparoscopic roux-en-y gastric bypassCholethiasis
Hypertension
DISEASE
Non-insulin-dependent
diabetes mellitus
DISEASE
Dyslipidemia
DISEASE
Discharge Condition:GoodDischarge Instructions:Please stay on stage 3 diet until follow-up. Do notself-advance diet drink from a straw or chew gum. No heavylifting (Admission Date: [**2163-11-11**] Discharge Date: [**2163-11-20**]Service: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Last Name (NamePattern1) 1561**]Chief Complaint:
Right lung cancer
DISEASE
Major Surgical or Invasive Procedure:Bronchoscopy x3PleurX catheter insertionEmergent intubationHistory of Present Illness:This patient is an 83 year old female with
small cell lung
DISEASE
cancer
DISEASE
who was accepted in transfer from [**Hospital 1562**] Hospital.Patient is with known right small cell lung cancer undergoingchemotherapy/radiation therapy at [**Hospital3 1563**] [**Hospital3 **]. Shenow presents with acute respiratory falure and is status-postintubation. The reports from the outside hospital indicateextrinsic compression from right mainstem bronchus obstructingthe proximal airway now with complete collapse of the righthemithorax with partial collapse of the left hemithroax. CTscans from [**Hospital1 1562**] indicate a large
volume tumor
DISEASE
encasing theright lung. The patient's family was advised of her dismalprognosis and the patient was admitted for the possibility of ameaningful intervention with the goal of palliative therapy.Past Medical History:End stage small cell lung canger with known brain
metastasis
DISEASE
Now s/p chemo/radiation therapy
Breast cancer
DISEASE
X-Ray therapy
pneumonitis
DISEASE
COPD
DISEASE
Osteoporosis
DISEASE
Physical Exam:T 98.4 HR 86 BP 108/45 RR 22 SpO2 95% on AC0.45/450/14/PEEP5Intubated sedatedRRRCTA on the left minimal breath sounds on the rightAbdomen soft
NT/ND
DISEASE
Extremeties with 1Admission Date: [**2133-5-13**] Discharge Date: [**2133-5-15**]Date of Birth: [**2088-3-11**] Sex: FService: MEDICINE
Allergies
DISEASE
:PenicillinsAttending:[**Doctor First Name 1402**]Chief Complaint:
palpitations
DISEASE
Major Surgical or Invasive Procedure:s/p DC - cardioversion on [**2133-5-14**]History of Present Illness:In brief 45 yo woman with history of
SVT
DISEASE
(long R-P) followedfor 5 years episodes monthly usually lasting Admission Date: [**2109-11-13**] Discharge Date: [**2109-11-25**]Date of Birth: [**2032-8-21**] Sex: MService: MEDICINE
Allergies
DISEASE
:Penicillins / Sulfonamides / HytrinAttending:[**Last Name (NamePattern1) 1572**]Chief Complaint:SOBMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:The patient is a 77 yo M with h/o
CHF
DISEASE
c/o
dyspnea
DISEASE
and 23lb wt.gain in last 10 days. The patient was discharged from [**Hospital1 18**] 10days ago. He has been followed closely by VNA and hiscardiolgoist. His lasix doses have been progressively increasedbut his weight has been going up and he has been havingworsening SOB. Denies CP SOB
fevers chills
DISEASE
..In the ED initial vitals were 97.7 94 125/69 24 83%4L. O2 sat'simproved to the high 90's on
NRB
DISEASE
. BNP Admission Date: [**2110-5-20**] Discharge Date: [**2110-6-3**]Date of Birth: [**2032-8-21**] Sex: MService: MEDICINE
Allergies
DISEASE
:Penicillins / Sulfonamides / HytrinAttending:[**First Name3 (LF) 898**]Chief Complaint:Admission Date: [**2110-8-8**] Discharge Date: [**2110-8-12**]Date of Birth: [**2032-8-21**] Sex: MService: MEDICINE
Allergies
DISEASE
:Penicillins / Sulfonamides / Hytrin / SildenafilAttending:[**First Name3 (LF) 800**]Chief Complaint:1) leg
ulcer
DISEASE
2) SOB 3)
abdominal pain
DISEASE
and
nausea
DISEASE
Major Surgical or Invasive Procedure:[**8-10**] US guided RLQ paracentesis (4L)History of Present Illness:77 y/o man with PMH significant for severe right sided heartfailure
pulmonary hypertension COPD
DISEASE
with
interstitial lung
DISEASE
disease and
chronic kidney disease
DISEASE
who presents with 3 day hxof
ulcer
DISEASE
on his right leg pt denies
trauma
DISEASE
to leg
fevers
DISEASE
orsweats. At baseline pt has mild
pedal edema
DISEASE
and there was nosignificant
swelling
DISEASE
of the right leg. Pt has some baseline
erythema
DISEASE
of bil lower legs but noted moderate increased
erythema
DISEASE
around
ulcer
DISEASE
and 'pus' which he described as yellow.The patient is on home 02 around the clock and has been on 4L NCfor several months. Pt has had no recent changes in hisbreathing at home and normally sats in the low 90s he deniesnew SOB or
dyspnea
DISEASE
. He has a chronic
cough
DISEASE
which has notchanged recently. He sleeps on his side on 2 pillows and deniesPND. He has had no
chest pain
DISEASE
. He denies
hematemesis
DISEASE
at home.In the ED he was satting 88% on 4L NC and then desaturated to70s and was placed on a
NRB
DISEASE
and satting 100%. He receivedPrednisone 60mg for
COPD
DISEASE
flair lasix 40mg IV x 1 and Vanco 1gIV. He then developed some diffuse
abdominal pain
DISEASE
and
nausea
DISEASE
andreceived zofran 4mg IV x2 and ativan 0.5mg x1.ROS: Denies
chest pain chills fevers
DISEASE
night
sweats cough
DISEASE
headache vision
DISEASE
changes
diarrhea dysuria melena
DISEASE
or
hematochezia
DISEASE
. Has 2
pillow orthopnea
DISEASE
. Uses BiPAP at night.
Denies stroke TIA
DISEASE
DVT PE
joint pains hemoptysis
DISEASE
. He doesreport a chronic
dry cough
DISEASE
which is at his baseline.Past Medical History:--
Hypertension
DISEASE
--
Hyperlipidemia
DISEASE
-- BPHAdmission Date: [**2151-5-21**] Discharge Date: [**2151-5-25**]Date of Birth: [**2079-12-14**] Sex: FService: MedicineHISTORY OF PRESENT ILLNESS: This is a 71-year-old woman witha chief
complaint
DISEASE
of
hematemesis
DISEASE
.The patient with a history of
chronic obstructive pulmonary
disease
DISEASE
and
peptic ulcer disease
DISEASE
40 years agoAdmission Date: [**2105-4-16**] Discharge Date: [**2105-4-27**]Date of Birth: [**2044-3-8**] Sex: FService: MEDICINE
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 2344**]Chief Complaint:Airway monitoringMajor Surgical or Invasive Procedure:[**2105-4-24**]: Right video-assisted thoraoscopy with decorticationHistory of Present Illness:61 year old female with PMHX of HTH presented with severe
sore
DISEASE
throat for 2 days rapidly getting worse associated withdifficulty swallowing liquids and
neck pain
DISEASE
. Also found to have
fever
DISEASE
and
tachycardia
DISEASE
. Unable to take meds only took BP medsthis am. Voice is
hoarse
DISEASE
and descrbed as Admission Date: [**2158-5-3**] Discharge Date: [**2158-5-6**]Date of Birth: [**2079-12-14**] Sex: FService: MEDICINE
Allergies
DISEASE
:Ativan / Valium / Haldol / Adhesive Tape / Sulfonamides /Codeine / Morphine / Erythromycin/Sulfisoxazole / AmoxicillinAttending:[**First Name3 (LF) 1650**]Chief Complaint:
dyspnea
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:Pt is a 78 yo f with h/o
COPD
DISEASE
with home O2 3L requirement CADs/p CABG in [**2140**]
CHF
DISEASE
with EF 30%
PVD
DISEASE
s/p aortofemoral bypassRLL
granuloma HL
DISEASE
and h/o
dementia
DISEASE
who presents to the ED inrespitatory distress. Pt and son gave history in the [**Name (NI) **] thatthat she became more SOB with increased o2 requirement (unknownhow much she increased it to). She came in to the hospitaltonight for SOB and reported some increase in her
allergies
DISEASE
butno
fever
DISEASE
.In the ED her vitals soon after arrival were HR 110s BP 194/79RR30 o2 sat 94% on 8L face mask. She was found to be in obvious
respiratory distress
DISEASE
using accessory muscles tachypnic poorair flow and speaking in one word sentences. She becamediaphoretic with CP and got 0.4mg of SL nitro with resolution of
chest pain
DISEASE
. She became tachy to 123 with RR 37 and BP 200/90then was started on a nitro gtt at 2mg/kg/hr which was increasedto 3mg/kg/hr. At some point dropped her sats to 85%. She wasstarted on BiPAP with obvious improvement. Her CXR showed pulm
vascular congestion
DISEASE
. She was given 2mg IV magnesium solumedrol125 IV x1 azithromycin 500mg for
COPD
DISEASE
exacerbation. Her EKGshowed sinus tach with prominent p waves and
LVH
DISEASE
as well as STelevation in v1 & v2 which was similar to prior. Cardiology wasconsulted and said this is likely strain in the setting of
respiratory distress
DISEASE
. Exam notable for
wheezes
DISEASE
poor airmovement and rhonci throughout. She received 20 IV lasix priorto leaving the ED. Vitals at time of transfer were HR 101 BP159/64 RR30 02 sat 100% on BiPap.On the floor VS were BiPAP 8/8 Fio2 100 with afebrile RR 25 HR99 BP 149/55. She was wearing the BiPAP but able to answer yesand no to questions. Able to confirm history that last few dayshad increased SOB non productive
cough wheezing weakness
DISEASE
andincreased
allergies
DISEASE
including
nasal congestion runny nose
DISEASE
andsinus pressure.Review of systems:(Admission Date: [**2148-1-22**] Discharge Date: [**2148-2-16**]Date of Birth: [**2089-6-30**] Sex: MService: HEPATOBILIARY SURGERYHISTORY OF PRESENT ILLNESS: The patient is a 58 year oldmale with a past medical history remarkable for
pericarditis
DISEASE
diverticulosis
DISEASE
status post colostomy and take-down
obstructive sleep apnea
DISEASE
who was evaluated for painless
jaundice
DISEASE
in [**2147-12-6**]. The patient's CT scan revealed1.6 by 2.0 centimeter
Klatskin tumor
DISEASE
with no evidence of
liver mass
DISEASE
nor encasement of vessels. The patient underwentan endoscopic retrograde cholangiopancreatography whichshowed normal
pancreatic duct
DISEASE
but
biliary stricture
DISEASE
consistent with
cholangiocarcinoma
DISEASE
. A stent was placed inthe upper third of the common bile duct. An MRCT in [**2147-12-6**] revealed a 2 centimeter mass in the porta hepatisconsistent with
cholangiocarcinoma
DISEASE
with extensive periportal
lymphadenopathy
DISEASE
.After a long discussion with the patient and family membersthe patient was taken to the Operating Room on [**2148-1-22**].PAST MEDICAL HISTORY: As noted above.MEDICATIONS: None.ALLERGIES: No known
drug allergies
DISEASE
.SOCIAL HISTORY: Positive tobacco smoker for 25 years.PHYSICAL EXAMINATION: At the time of discharge the patientwas well developed and well nourished in no apparentdistress. HEENT: Sclerae was
icteric
DISEASE
with evidence of
jaundice
DISEASE
. Cranial nerves II through XII intact. Mucousmembranes were moistAdmission Date: [**2157-7-25**] Discharge Date: [**2157-7-28**]Date of Birth: [**2110-12-29**] Sex: FService: MEDICINE
Allergies
DISEASE
:Codeine / Compazine / ZofranAttending:[**First Name3 (LF) 1674**]Chief Complaint:suicidal attemptMajor Surgical or Invasive Procedure:noneHistory of Present Illness:46 yo F with a history of
depression
DISEASE
admitted after intentional
overdose
DISEASE
of benzodiazepines fluoxetine and phenytoin..By verbal report at 8AM the patient ingested (based upon pillbottles) an estimated 30 lorazepam 30 prozac 35 clonazepam 3unisom and 4 dilantin. She was reportedly suicidal and herhusband had to break down the door to get to her. The patientreports that she had
depressed mood
DISEASE
for several months. Sherecalls taking 'like a handful' of clonazepam fluoxetine andphenytoin. She states that she has a great deal of stress athome related to her children and husband and the only way todeal with this difficulty is to 'leave this world.' She deniesongoing thoughts of wanting to hurt herself..In the ED 98.6 72 138/64 14 99%
RA
DISEASE
. She developed
hypotension
DISEASE
with a single bp measurement of 80/50 pulse 62. She received1.5L NS with improvement in the blood pressure back to Admission Date: [**2161-8-4**] Discharge Date: [**2161-8-7**]Date of Birth: [**2110-12-29**] Sex: FService: SURGERY
Allergies
DISEASE
:Codeine / Compazine / VicodinAttending:[**First Name3 (LF) 1390**]Chief Complaint:s/p fallMajor Surgical or Invasive Procedure:noneHistory of Present Illness:50 y.o. F w/ h/o
sucharachnoid cyst
DISEASE
&
psychiatric
DISEASE
history whopresented s/p fall down a flight of stairs. She has aquestionable
seizure
DISEASE
history and she is also on multiple
psychiatric
DISEASE
medications at home. In the ED she had alteredmental status and was intubated for airway protection.Past Medical History:
Chronic hemorrhoids Hematuria Anemia
DISEASE
of
chronic disease
DISEASE
GERD
Arachnoid cyst
DISEASE
fenestration w/ right craniotomy [**2157-2-22**]
Seizures
DISEASE
secondary to above
Glaucoma
DISEASE
AsthmaPSHx:
subarachnoid cyst
DISEASE
excision ([**2157**]) right cystoperitonealshunt ([**2161-6-9**])Social History:negative for tobacco or EtOHFamily History:NCPhysical Exam:ICU physical exam:Gen: somnolent minimally responsiveCV: tachycardic regular rhythmPulm: CTABAbd: soft nontender nondistendedExt: WWP no
edema
DISEASE
Exam on discharge:VS: 98.3 73 126/65 20 94%RAGEN: A&OX3 NADCHEST: CTAB RRRABD: Soft nontender nondistendedEXTR: L thigh with lg echymosis soft. LE warm pink and wellperfused. No
edema
DISEASE
. Admission Date: [**2141-11-7**] Discharge Date: [**2141-11-13**]Date of Birth: [**2091-11-1**] Sex: MService: GU
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1232**]Chief Complaint:Sharp
abdominal pain
DISEASE
after
cough
DISEASE
gross
hematuria
DISEASE
Major Surgical or Invasive Procedure:s/p right partial nephrectomy on [**2141-10-24**]History of Present Illness:Pt is a 50 year old male who underwent a right partialnephrectomy on [**2141-10-24**] and was discharged and presented to theER on [**2141-10-30**] after an MVA with
complaint
DISEASE
of
serosanguinous
DISEASE
discharge from old chest tube site. Chest xray and ultrasound atthe time were negative. The patient then returned to hospital on[**2141-11-7**] with a
complaint
DISEASE
of severe
abdominal pain
DISEASE
and oneepisode of gross
hematuria
DISEASE
after a
cough
DISEASE
. The patient presentedto an outside hospital with a hematocrit of 27 and a BP of70/40. The patient was given IV fluids and 1 unit of PRBC's(post-transfusion hematocrit was 29) was stabilized and thenmed flighted to [**Hospital1 18**].Past Medical History:
IgA nephropathy
DISEASE
Hypertension
DISEASE
Gout
DISEASE
Psoriasis
DISEASE
Social History:Patient has a significant alcohol history of [**7-11**] drinks/dayFamily History:Non-contributoryPhysical Exam:Gen: AAdmission Date: [**2189-2-5**] Discharge Date: [**2189-2-15**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1711**]Chief Complaint:s/p collapseMajor Surgical or Invasive Procedure:IntubationCentral venous line placementHistory of Present Illness:[**Age over 90 **] yo F hx IDDM
HTN
DISEASE
who presented after she collapsed in thelobby of her building while awaiting her son to pick her up forappointment to see her PCP. [**Name10 (NameIs) **] was reportedly feeling wellrecently according to son no
infectious symptoms
DISEASE
. She camedown to the lobby and sat in a chair while waiting and thencollapsed. Pt had CPR initiated from bystanders (RN and aide inlobby) per report EMS on presentation noted VFib wasdefibrillated 200J x1. Review of provided strip appears todemonsrate a
NSR
DISEASE
with artifact followed by
shock
DISEASE
and resumptionof NSR. FS was 188 unresponsive intubated in the field. Pt
hypotensive
DISEASE
to 60's on arrival to ED rec'd 1.5 L NS started onlevophed transiently. Pt had
head chest/abd
DISEASE
CTs performedwhich were unrevealing.Past Medical History:
IDDM
DISEASE
c/b
retinopathy neuropathy
DISEASE
HTN
DISEASE
H/O FRONTAL LOBE MENINGIOMA - RESECTED IN [**2124**]S/P HEMORROIDECTOMYS/P T AND ASocial History:lives by herself independently no prior hx of tobacco.Family History:NCPhysical Exam:VS: T 93.4 BP 156/60 HR 58 RR 16 O2 % onGen: elderly female sedated intubated unresponsive.HEENT: Pupils 2mm nonreactive.CV: RRR nl S1 S2 no m/r/gChest: breath sound b/lAbd: soft ND no HSMExt: 2Admission Date: [**2131-9-6**] Discharge Date: [**2131-9-13**]Date of Birth: [**2062-7-11**] Sex: MService: CSUHISTORY OF PRESENT ILLNESS: Please note this is fromCardiology's dictated pre catheterization admission note asthere was no history and physical examination from hispreoperative visit in the chart.This is a 69-year-old male patient of Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]with a longstanding history of
exertional angina
DISEASE
and abnormalstress test now with worsening symptoms who was referred foroutpatient catheterization to [**Hospital1 188**]. He reports that for the past five to six years hehas been experiencing
exertional back pain
DISEASE
until recently.It occurred with activity such as walking and was resolvedwith rest. Over the past two to three weeks he feels thathis symptoms have gotten worse. The
pain
DISEASE
is now radiating tohis chest and seems to last for a longer period of timerequiring nitroglycerin for relief. He also reports having
dyspnea
DISEASE
after climbing hills. He does report occasionallyhaving symptoms at rest over the past few weeks for which hetakes nitroglycerin with relief. He states this occurs oneto two times per week on average.PAST MEDICAL HISTORY:1. Positive exercise tolerance test.2.
Hypertension
DISEASE
.3.
Hyperlipidemia
DISEASE
.4. Occasional lightheadedness upon waking in the morning.5.
Duodenal ulcer
DISEASE
with
melena
DISEASE
in [**2119**].6.
Thrombocytosis
DISEASE
.7. Prostate cancerAdmission Date: [**2192-8-7**] Discharge Date: [**2192-8-21**]Date of Birth: [**2130-11-19**] Sex: FService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1234**]Chief Complaint:left lower leg extremity
ischemia
DISEASE
Major Surgical or Invasive Procedure:s/p Left femoral-below knee popliteal bypassHistory of Present Illness:This is a 61-year-old female who has a historyof a left femoral to above-knee popliteal bypass withprosthetic due to a previous harvesting for CABG of hersaphenous vein. The patient also has a history of stentingand angioplasty of the distal popliteal artery. The patientpresented to the hospital with increasing left foot
pain
DISEASE
andwas found on angiography to have a completely
thrombosed
DISEASE
prosthetic graft. She had suitable runoff from the
below-knee
DISEASE
popliteal artery and the decision was made to perform a redobypass operation.Past Medical History:PVD (Fem stent [**6-12**])B CEA
IDDM
DISEASE
RAS
HTN
DISEASE
CAD (MI '[**70**]
CABGx3
DISEASE
'[**71**])CRIBreast implants
Depression
DISEASE
Social History:80 pack year history quit in [**2170**]no alcoholFamily History:non contribPhysical Exam:On day of discharge patient was feeling well withoutcomplaints vital signs stable. T 98.3 Pulse 74 BP 140/40 RR18 O2 sats 96%
RA
DISEASE
The patient was not in any acute distress alert and oriented x3 and not in any
pain
DISEASE
.CVS- regular rate and rhythmPulm- clear to auscultation bilaterallyAbd- non distended soft non tenderWound- left leg- clean dry and intactPulses palpable bilaterally fem [**Doctor Last Name **] dp ptPertinent Results:[**2192-8-17**] 03:40AM BLOOD WBC-15.0* RBC-3.22* Hgb-9.9* Hct-29.8*MCV-93 MCH-30.6 MCHC-33.1 RDW-14.4 Plt Ct-495*[**2192-8-7**] 07:45PM BLOOD Neuts-63 Bands-0 Lymphs-27 Monos-5 Eos-4Baso-1 Atyps-0 Metas-0 Myelos-0[**2192-8-17**] 03:40AM BLOOD Plt Ct-495*[**2192-8-17**] 03:40AM BLOOD PT-14.0* PTT-33.0 INR(PT)-1.2*[**2192-8-19**] 06:10AM BLOOD Glucose-118* UreaN-54* Creat-1.5* Na-136K-4.0 Cl-100 HCO3-28 AnGap-12[**2192-8-19**] 06:10AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.5Blood culture all negativeBrief Hospital Course:The patient was admitted on [**2192-8-7**] for a left lower extremitybypass on [**2192-8-8**]. The patient underwent a left fem-bk [**Doctor Last Name **] withright arm vein (cephalic Admission Date: [**2140-11-16**] Discharge Date: [**2140-11-24**]Date of Birth: [**2080-4-23**] Sex: MCHIEF COMPLAINT: Cough/shortness of breath.HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 1726**] is a 60-year-old malewith a past medical history significant for
hypertension
DISEASE
times two who developed a
dry cough
DISEASE
in late [**Month (only) **] whilefly fishing in [**State 1727**]. The
cough
DISEASE
persisted and he was givenerythromycin times ten days times two courses by his primarycare physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1728**]. The erythromycin did not improvethe patient's symptoms.The patient describes the
cough
DISEASE
as
dry
DISEASE
not worse at nightbreath. He denied
fevers
DISEASE
and chills. He states that helost about six pounds over the past two months intentionally.Over the past one to two weeks however he has notedincreasing
dyspnea
DISEASE
with stairs as well as
fatigue
DISEASE
. On theday prior to admission he started a Z pack.At his primary care physician's office today he had a chestx-ray which disclosed an enlarged heart and interstitialinfiltrates. An esophagogastroduodenoscopy was done as wellas an echocardiogram which disclosed evidence of a
pericardial effusion
DISEASE
with
tamponade
DISEASE
.There was diastolic collapse of the right atrium and rightventricle. The patient was sent to the Emergency Departmentat [**Hospital6 256**] for evaluation of the
pericardial effusion
DISEASE
and drainage. His pulses paradoxes was18. The echocardiogram performed in the Emergency Departmentwas consistent with
cardiac tamponade
DISEASE
. The patient remainedhemodynamically stable.PAST MEDICAL HISTORY:1. Melanoma. Patient is status post removal of
melanoma
DISEASE
in[**2118**] and in [**2138**].2. Empyema of the left lung in [**2122**].3. Labile
hypertension
DISEASE
.4. Overweight.5.
Hypercholesterolemia
DISEASE
.6. Myxomatous
mitral valve prolapse
DISEASE
with mild mitralregurgitation.7. Non-sustained
ventricular tachycardia
DISEASE
.8. Chronic asymptomatic VEA.9.
Peripheral vision loss
DISEASE
.10. History of smoking quit in [**2122**].MEDICATIONS:1. Tenormin 150 mg q.d.2. Lipitor 80 hs.3. Enteric coated aspirin 325 mg po q.d.4. Accupril 20 mg po q.d.5. Multivitamin.6. Folate 2 tablets b.i.d.7. Vitamin E.8. Vitamin B6.9. Vitamin B12.10. Ativan prn sleep.ALLERGIES: Penicillin. Patient has a
rash
DISEASE
.SOCIAL HISTORY: Patient does office work. He has been awidow for the past nine years. He coaches a girls basketballteam. He has two children ages 30 and 25. He lives withhis 30-year-old daughter. [**Name (NI) **] has a 2-year-old grandchild.He smoked cigars until [**2122**]. He has not had alcohol for thepast nine years.FAMILY HISTORY: No
heart disease
DISEASE
and no
diabetes mellitus
DISEASE
.REVIEW OF SYSTEMS: No
fevers chills
DISEASE
or night sweats.Patient reports a six pound intentional
weight loss
DISEASE
over thepast two months. No history of positive PPD or
Tuberculosis
DISEASE
exposure. No upper respiratory infection symptoms with
cough
DISEASE
. No
nausea vomiting diarrhea
DISEASE
or
abdominal pain
DISEASE
butoccasionally Admission Date: [**2141-1-4**] Discharge Date:[**2141-1-12**]Date of Birth: [**2080-4-23**] Sex: MService:OncologyCHIEF COMPLAINT: Short of breath times one week plusweakness.HISTORY OF PRESENT ILLNESS: The patient is a 60-year-oldmale with a history of metastatic
lung cancer
DISEASE
to brainfailure to thrive. He had a recent diagnosis on [**11-5**] of
lung adenocarcinoma
DISEASE
with metastases to [**Last Name (LF) 500**] [**First Name3 (LF) **]pericardium. He had a recent admit for malignant pericardialeffusion with
tamponade
DISEASE
status post drainage on [**11-5**]. Planfor chemotherapy after patient completes XRT. Had an Lumbarpuncture on [**11-29**] with negative meningeal spread of
cancer
DISEASE
.He has noted one week prior to admission progressive increaseHe had a pulses paradoxus of 15 in the emergency department.No
fever chills chest pain cough nausea vomiting
DISEASE
diarrhea abdominal pain
DISEASE
. He had a normal p.o. intake butdecreased ambulation secondary to weakness post XRT. Can goapproximately 10 steps and then gets tired with short ofbreath.In the emergency department he got a dose of Levofloxacin forconcern of
pneumonia
DISEASE
and
bronchitis
DISEASE
and stress dose steroids.Chest x-ray shows increased in cardiac silhouette.Electrocardiogram showed alternans. Bedside echo concerningfor
tamponade
DISEASE
. Catheterization laboratory for pericardialdrain placement. Got 2500 cc's removed.PAST MEDICAL HISTORY: Significant for
hypertension
DISEASE
hypercholesterolemia mitral valve prolapse
DISEASE
status post
melanoma
DISEASE
. Status post resection in [**2118**] and [**2138**]. Empyemaleft lung [**2122**] status post thoracotomy and
supraventricular
DISEASE
tachycardia
DISEASE
. Lung adenocarcinoma with metastases to brain[**Year (4 digits) 500**] pericardium. Now undergoing brain XRT. Atrial
flutter peripheral visual loss
DISEASE
.An echo on [**11/2134**] showed EF greater than 55%MEDICATIONS ON ADMISSION:1. Decadron 4 mg q AM 2 mg q PM.2. Zantac 150 mg b.i.d.3. Sotalol 80 mg twice a day.4. Ambien 10 mg q h.s.5. Lipitor 80 mg q h.s.6. Folate 1 mg q day.7. Accupril 10 mg q day.8. ASA 81 mg q day.ALLERGIES: Penicillin which causes a
rash
DISEASE
.SOCIAL HISTORY: Lives with a daughter at home. No tobaccoin the past 20 years no alcohol.PHYSICAL EXAMINATION: On admission in general no acutedistress pleasant slightly tachypneic. Vital signs 97.5heart rate 94 blood pressure 99/61. Respiratory rate 3699% on 100% face mask. Left pupil minimally reactive downvisual acuity. OP clear. Neck: No jugular venousdistention. Pulmonary: Coronary
artery disease
DISEASE
bilaterally.Carotids: Regular rate and rhythm. No murmurs. Abdomen:Soft nontender no distension. Bowel sounds positive.Extremities: No
cyanosis clubbing
DISEASE
or
edema
DISEASE
. 2Admission Date: [**2198-4-23**] Discharge Date: [**2198-5-8**]Date of Birth: [**2122-10-14**] Sex: MService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 148**]Chief Complaint:
fever
DISEASE
Major Surgical or Invasive Procedure:1. Exploratory laparotomy.2. Pancreatic debridement with wide drainage.3. Open cholecystectomy.4. Placement of a combined G/J tube (MIC tube).5. PICC line placement6. ERCP with stentHistory of Present Illness:This is a 75 year old man who is a retired anethesiologist withh/o CAD s/p CABG and
ischemic cardiomyopathy
DISEASE
with EF of 25% whowas recently discharged from [**Hospital1 18**] following a hospital coursefor
gallstone pancreatitis
DISEASE
and now re-presents from rehab for
fevers
DISEASE
. During last admission he was transferred from OSH withwith
fever
DISEASE
and
pancreatitis
DISEASE
which was thought to be from
gallstones
DISEASE
although there were no
gallstones
DISEASE
in the bile ductsjust in the gallbladder itself. CT scan done on admissionw asconsistent with severe
pancreatitis
DISEASE
. ERCP was done on [**2198-4-6**]with sphinceterotomy and CBD stent placed. His post procedurecourse was complicated by
fevers
DISEASE
and repeat CT abd showsprogression of severe
pancreatitis
DISEASE
with extensiveperipancreatitis fluid collection. This was thought to beeither from PNA or from
inflammation
DISEASE
from his
pancreatitis
DISEASE
. Hefinished a course of azithro/ctx and a course of flagyl/ciproand eventually he devefesced. All cultures were negative. Hewas discharged to rehab..At rehab he reports having
fevers
DISEASE
since Friday [**2198-4-21**] withhighest at 102.0. He has no localizing
pain
DISEASE
. Denies cough
dysuria
DISEASE
abd
pain
DISEASE
or
nausea
DISEASE
and
vomit
DISEASE
..ROS: Negative for
headache
DISEASE
chest pain shortness
DISEASE
of breath orchange in bowel habits.Past Medical History:#
Coronary artery disease
DISEASE
status post CABG x4 in [**2183**].# Status post MI in [**2182**].# Ischemic
cardiomyopathy
DISEASE
EF 20-25% echo [**2194**].#
Atrial flutter
DISEASE
currently A-paced.#
Ventricular irritability
DISEASE
.# ICD placement [**2193**] changed in [**2195**] ([**Company 1543**] dual- chambersystem.)# CRI with a baseline creatinine of 1.2-1.5.#
Gout
DISEASE
.#
Gallstones
DISEASE
.#
Kidney stones
DISEASE
.# h/o
Syncope
DISEASE
.Social History:A retired anesthesiologist worked in
pain
DISEASE
management. Deniestobacco drugs. Bottle of wine per week.Family History:Father had a MI at age 70.Physical Exam:VITALS: 102.2 112/P 68 16 93%-RAGEN: AAdmission Date: [**2141-1-4**] Discharge Date: [**2141-1-12**]Date of Birth: [**2080-4-23**] Sex: MService:OncologyDISCHARGE DIAGNOSES:1.
Non-small cell lung carcinoma
DISEASE
metastatic to [**Last Name (LF) 500**] [**First Name3 (LF) **]and pericardium.2.
Pericardial tamponade
DISEASE
requiring
pericardiocentesis
DISEASE
.3. Hypoxia due to
multifactorial lung disease
DISEASE
.DISCHARGE MEDICATIONS:1. Ambien 10 mg p.o. q.h.s.2. Sotalol 80 mg p.o. b.i.d.3. Multivitamin one p.o. q.d.4. Tylenol 225 to 650 mg p.o. q. four to six hours p.r.n.5. Colace 100 mg p.o. b.i.d.6. Protonix 40 mg p.o. q.d.8. Morphine Sulfate 1 to 5 mg IV q. four to six hours p.r.n.9. Dibutoline one application TP q.i.d. p.r.n.10. Methylprednisone 80 mg p.o. b.i.d..11. Albuterol nebs q. four to six hours.12. Atrovent nebs q. four to six hours.13. Levofloxacin 500 mg p.o. q.d. till [**2141-1-19**].13. Bactrim Double Strength tabs one p.o. b.i.d. till[**2141-1-19**].14. Percocet one to two tabs p.o. q. four to six hours p.r.n.He was discharged to [**Hospital 1739**] Hospice in stable condition.He is DNI DNR and moving towards comfort care only. [**Known firstname **] [**Last Name (NamePattern4) 1735**] m.d. [**MD Number(1) 1736**]Dictated By:[**Last Name (NamePattern1) 1737**]MEDQUIST36D: [**2141-1-11**] 10:20T: [**2141-1-11**] 10:15JOB#: [**Job Number 1740**]Admission Date: [**2181-9-5**] Discharge Date: [**2181-9-14**]Service: CARDIACHISTORY OF THE PRESENT ILLNESS: The patient is an82-year-old female with
hypercholesterolemia
DISEASE
chronic renalinsufficiency
hypertension
DISEASE
and long history of atypical
chest pain
DISEASE
as well as possibly asymptomatic myocardial
infarction
DISEASE
a long time ago. Prior to admission the lastcardiac evaluation was in [**Month (only) 956**] when a stress MIBI showedan ejection fraction of 67% without evidence of
ischemia
DISEASE
although the patient only tolerated three minutes.The patient was in the usual state of health until severalmonths ago when she began to complain of increased
shortness
DISEASE
of
breath and pedal edema
DISEASE
. The symptoms specifically
shortness of breath and chest pain
DISEASE
increased in intensityabout two weeks prior to admission. On [**2181-9-3**] thepatient presented to her primary care physician and stresstests were performed. On the night prior to admission thepatient presented with
left sided substernal chest pain
DISEASE
radiating to the scapula that had lasted for 10 to 12 hours.The patient lasted all night prior to admission withoutsignificant relief from sublingual nitroglycerin. Thepatient complained of
nausea shortness
DISEASE
of breath. Thepatient was not diaphoretic. EKG performed at the timeshowed ST elevations in leads V1 through V3 and loss of Rwave. The patient was given Morphine nitropaste and aspirinaccording to protocol.PAST MEDICAL HISTORY:1.
Hypertension
DISEASE
.2.
Hypercholesterolemia
DISEASE
.3. Gout.4. Arthritis.5. Multinodular
goiter
DISEASE
.6. History of appendectomy.7. Possible history of
myocardial infarction
DISEASE
in distantpast.ALLERGIES: The patient is
allergic
DISEASE
to AMIODARONE WHICHCAUSES FACIAL EDEMA.MEDICATIONS ON ADMISSION:1. Aspirin 325 mg PO q.d.2. Diltiazem CD 180 PO q.d.3. Hydrochlorothiazide 25 q.d.4. Lipitor 10 mg PO q.d.5. Lopressor 25 mg PO b.i.d.6. Nitroglycerin patch 10 mg PO q.d.7. Vasotec 75 mg PO b.i.d.8. Allopurinol 100 mg q.d.FAMILY HISTORY: Noncontributory.PHYSICAL EXAMINATION: Examination revealed the following:Vital signs afebrile. Heart rate: Admission Date: [**2200-6-2**] Discharge Date:[**2200-7-8**]Date of Birth: [**2131-8-1**] Sex: FService:DATE OF DISCHARGE: Pending.AGE: 68.HISTORY OF THE PRESENT ILLNESS: [**Known firstname 1743**] [**Last Name (NamePattern1) 1744**] is a68-year-old female who was at acute rehabilitation at[**Location (un) 38**] after having a right-sided knee replacement on[**2200-5-6**]. The patient had been on antibiotics following herknee replacement and had developed
abdominal pain
DISEASE
two weeksprior to admission with
diarrhea
DISEASE
. The patient was presumedto have
C. difficile
DISEASE
and had been started on Flagyl. She wastaken to the [**Hospital1 69**] EmergencyDepartment and on presentation she had a white blood cellcount of 25000 large amounts of
nausea
DISEASE
and
fevers
DISEASE
up to101.0 degrees. Of note the patient had been on Flagyl since[**5-21**] until the patient's presentation on [**2200-6-2**].REVIEW OF SYSTEMS: Review of systems was negative for
dysuria
DISEASE
.PAST MEDICAL HISTORY: History was notable for the following:1. Osteoarthritis.2. Left sided
breast cancer
DISEASE
.3. Diverticulitis.4. Gastrointestinal bleed.5. Fibromyalgia.MEDICATIONS ON ADMISSION:1. Coumadin.2. Vistaril.3. ....................4. Tamoxifen.5. Zoloft.6. Protonix.7. Ditropan.8. [**Doctor First Name **].9. Lasix.ALLERGIES: The patient is
allergic
DISEASE
to SULFA AND IBUPROFEN.SOCIAL HISTORY: The patient has no history of alcoholdrugs or smoking.PHYSICAL EXAMINATION: On presentation the patient'sphysical examination revealed the following: Temperature100.3 heart rate 109 blood pressure 149/74 respiratoryrate 18 oxygen saturation 97%. She was ill-appearing onpresentation with a diffusely tender abdomen with positiverebound and no guarding. Stool was guaiac negative.HOSPITAL COURSE: The patient was then admitted medicalservice initially for management of her presumed
C. difficile
DISEASE
colitis
DISEASE
.The patient was admitted to the medical servicepostoperatively and then was noted to have
pleural effusion
DISEASE
and then underwent a thoracocentesis of her effusion. On the14th the patient continued to have poor hospital course andon [**2200-6-5**] due to difficult medical management of thedisease surgical consultation was obtained and the patientunderwent a subtotal colectomy with ileostomy.Regarding the patient's operation please referred toDr. [**Name (NI) 1745**] operative note on [**2200-6-5**]. Postoperativelythe patient was taken to the Medical Intensive Care Unit forfurther management of her disease. She underwent numeroustransfusion of fresh-frozen plasma. The patient wascontinued to be intubated. The patient was managed in theMedical Intensive Care Unit with bilateral chest tubes placedwhile the patient was in the Medical Intensive Care Unit.The patient continued to have high
fevers
DISEASE
. Sputum culturefrom [**2200-6-21**] demonstrated
Methicillin-resistant
DISEASE
Staphylococcus aureus and transthoracic cardiacechocardiogram demonstrated no
pericardial effusion
DISEASE
or noobvious
vegetations
DISEASE
while the patient continued to havethese
fevers
DISEASE
. The patient was continued on Vancomycin andcontinued to be intubated for a long period of time until[**2200-6-25**] when the patient was extubated successfully.Post extubation the patient had difficulty with her voiceand swallowing and she was deemed an aspiration risk soDobbhoff was placed. She was then transferred to the floorand she continued to do well. Chest tubes were removed andshe stopped having
fevers
DISEASE
. Physical therapy consultation wasobtained and the patient began to improved dramatically whileon the floor. She remained afebrile with stable vital signswith reasonable respiratory parameters and she was continuedon tube feeds or Promote with fiber at a goal rate of 70 ccper hour.The patient will be discharged to a rehabilitation facilityon the following regimen:1. Lopressor 50 mg PO t.i.d.2. Ambien 10 mg PO q.h.s.3. Vancomycin 1 gram q.d.4. Heparin 5000 units subcutaneously b.i.d.5. Regular insulin sliding scale.6. Protonix 40 mg IV q.d.7. The patient will continue on her tube feeds Promote withfiber at 70 cc an hour.FOLLOW-UP CARE: The patient will followup with Dr. [**Last Name (STitle) 519**] inone to two weeks. The patient will followup with her primarycare physician at the time deemed appropriate by theiroffice.OF NOTE: Portions of this chart were not available duringthis dictation. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] M.D. [**MD Number(1) 521**]Dictated By:[**Name8 (MD) 522**]MEDQUIST36D: [**2200-7-7**] 13:37T: [**2200-7-7**] 13:57JOB#: [**Job Number 1746**]Admission Date: [**2174-8-8**] Discharge Date: [**2174-8-17**]Service: [**Location (un) 259**] MEDICINEHISTORY OF PRESENT ILLNESS: The patient is a 79-year-oldwoman a resident of [**Hospital3 **] Facility with
end-stage dementia diabetes mellitus
DISEASE
and multiple othermedical problems who presented to [**Hospital6 649**] with a history of
lethargy cough fever
DISEASE
and
shortness of breath
DISEASE
.According to the [**Hospital 228**] [**Hospital3 **] chart thepatient had several recurrent temperatures to 101Admission Date: [**2175-5-3**] Discharge Date: [**2175-5-23**]Service: MEDICAL ICUHISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 1764**] is an 80 year-oldfemale with a past medical history significant for
dementia
DISEASE
presents as a transfer from HCRA with
fevers
DISEASE
and
hypotension
DISEASE
.Per available information the patient was in her usual stateof health until 9:30 in the morning of [**2175-5-3**] when shespiked a temperature to 104. She was seen by [**Name6 (MD) 1765**] cover MDand found to be bradycardic. A few hours later the patientwas found to be
hypotensive
DISEASE
with a systolic blood pressure inthe 50s. She was unresponsive. She was bolused 500 cc ofnormal saline without a change in blood pressure and wastransferred to the [**Hospital1 69**]Emergency Department at that point.Initial vital signs in the Emergency Room were temperature100.8. Blood pressure 54/27 with a pulse of 88.Respirations 28 with an O2 saturation of 91% on room airincreasing to 99% on 10 liters. She received 4 liters ofintravenous fluids antibiotics were started AmpicillinGentamycin and Flagyl and a left subclavian triple lumencatheter was placed. Physical examination wasnoncontributory initially. Initial laboratories were notablefor a white blood cell count of 10.9 with a
bandemia
DISEASE
.Urinalysis was very concentrated and multiple white bloodcells. Despite intravenous fluids systolic blood pressureremained low and she was started on a dopamine drip titratedto 15 mcs per minute and systolic blood pressure wasmaintained in the low 100s. At that point the patient wastransferred to the MICU for further evaluation.PAST MEDICAL HISTORY: 1. Dementia. 2. Hypertension. 3.
Glaucoma
DISEASE
. 4. Coronary
artery disease
DISEASE
. 5. Ischemic
cardiomyopathy
DISEASE
with EF of 40%. 6. PEG tube. 7. Paroxysmal
atrial fibrillation
DISEASE
on Amiodarone. 8. Type 2
diabetes
DISEASE
.MEDICATIONS ON TRANSFER: Sorbitol 30 mg po q day Amiodarone200 mg po q day vitamin C 500 units po q day aspirin 81 mgpo q day multivitamin q day Axid 150 mg po q day Risperdal10 mg po b.i.d. and zinc 220 mg po q day.PHYSICAL EXAMINATION: Afebrile 97.9. Heart rate 99. Bloodpressure 84/43. O2 sat 99% on nonrebreather. Generally wasunresponsive to oral stimuli or to sternal rub. Of notethepatient is Russian speaking only. HEENT pupils are equalround and reactive to light and accommodation. Extraocularmovements intact. Neck was supple without
lymphadenopathy
DISEASE
.Neck veins were flat. Chest was clear to auscultationbilaterally. Heart was tachycardic with distant heartsounds 2/6 systolic murmur at the left lower sternal border.Abdomen soft nontender nondistended. Normoactive bowelsounds. Extremities mild
pedal edema
DISEASE
.LABORATORY: White blood cell count 10.9 hematocrit 34.4platelet count of 214 INR 2.0 sodium 147 creatinine 2.0anion gap of 14. Her differential showed 62 polys and 20bands. Urinalysis was cloudy specific gravity of 1.015 pHof 8.5 large blood positive nitrite greater then 300protein large leukocyte esterase greater then 50 whiteblood cells and red blood cells with many bacteria. Chestx-ray showed diffuse left sided infiltrates.Electrocardiogram was sinus at 100 with normal axis andintervals Admission Date: [**2151-7-16**] Discharge Date: [**2151-8-4**]HISTORY OF PRESENT ILLNESS: The patient is an 86 year oldAfrican American female who on the morning of [**7-16**] wasfound on the floor of her unair-conditioned home by arelative during the heat wave. She was conscious butThe family reports she had not been drinking much and had notbeen feeling well one day prior to admission. The familyalso reports a productive
cough
DISEASE
30 lb
weight loss
DISEASE
in thelast three months
shortness of breath
DISEASE
over the last fewmonths worsened by exertion and increasing
edema
DISEASE
.The patient was taken to the Emergency Department and rectaland irregular. Blood pressure was 137/76 respiratory rate 27.Cooling measures were started in the Emergency Department.She was placed on a 100% oxygen nonrebreather mask. Thepatient gradually became alert and oriented times two. Inthe Emergency Department she subsequently became
hypotensive
DISEASE
with blood pressure of 80/49 heart rate 87 and irregular.More aggressive fluid resuscitation was started. She wasbriefly placed on a Norepinephrine drip for hemodynamicinstability which was later changed to a Levophed drip. Acentral line was placed. The patient's temperature graduallycame down to 98.6 over several hours. Laboratory studies andblood cultures were drawn. Chest x-ray was done.Electrocardiogram urinalysis arterial blood gases were doneandthe patient was started on broad spectrum antibiotics.PAST MEDICAL HISTORY: Cardiomyopathy-
idiopathic
DISEASE
echocardiogramin [**2141**] showed an ejection fraction of 20%.
Hypertension
DISEASE
.
Pulmonary hypertension
DISEASE
. Chronic
atrial fibrillation
DISEASE
. Intermittentleft
bundle branch block
DISEASE
. History of
anemia
DISEASE
and heme positivestools (previously refused colonoscopy). History of previous
pulmonary embolism
DISEASE
in [**2141**]. History of previous
stroke
DISEASE
in [**2141**].History of previous
myocardial infarction
DISEASE
(undocumented in[**2144**]).
Chronic right-sided pleural effusion
DISEASE
first found in[**2150-11-12**]. History of multiple episodes of
cellulitis
DISEASE
.Claustrophobia.MEDICATIONS ON ADMISSION: Coumadin 6 mg alternating 4 mgq.d. Lasix 20 mg q.d. Lisinopril 10 mg q.d. Diltiazem 300mg q.d. Digoxin 0.125 mg q.d.ALLERGIES: No known
drug allergies
DISEASE
.SOCIAL HISTORY: The patient is an African American femalewho lived alone. Family checks on her often and livesnearby.FAMILY HISTORY: There is a family history of
colon cancer
DISEASE
.PHYSICAL EXAMINATION: On physical examination (as noted inEmergency Department/Medicine Intensive Care Unit notes).General a thin malnourished African American femaledisoriented. Head eyes ears nose and throat pupils areequal round and reactive to light
extraocular movements
DISEASE
intact. Dry mucous membranes. Oropharynx clear. Necksupple. Jugulovenous distension noted to be 6 cm. Lungs
bibasilar
DISEASE
crackles denies
cough
DISEASE
. Rhonchi throughout. Nowheezes. Cardiovascular irregularly irregular rhythm
II/VI systolic murmur
DISEASE
. Abdominal positive bowel soundssoft nontender nondistended no rebound or guarding. Nomasses. Guaiac positive rectal examination. Extremitiesno
edema
DISEASE
severe chronic venous insufficiency/stasis
dermatitis
DISEASE
in the lower extremities 1Admission Date: [**2169-3-26**] Discharge Date: [**2169-4-9**]Date of Birth: [**2090-12-5**] Sex: FService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1781**]Chief Complaint:
Right foot pain
DISEASE
s/p stenting of right superficial femoral arteryMajor Surgical or Invasive Procedure:[**2169-3-30**] stenting of right superficial femoral arteryHistory of Present Illness:78 y.o female s/p angio of the SFA with stent on [**2169-3-14**]presents with RLE foot
pain
DISEASE
Past Medical History:
Adrenal insufficiency
DISEASE
hx hypercaoguable state - but no clear h/o
DVT/PE
DISEASE
hypercholestremia
DISEASE
Admission Date: [**2169-4-16**] Discharge Date: [**2169-4-25**]Date of Birth: [**2090-12-5**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 689**]Chief Complaint:78 yo F w/ abd
pain
DISEASE
Major Surgical or Invasive Procedure:right femoral lineright upper extremity PICCtransient levophedHistory of Present Illness:78 yo F w/ h/o hyperchol
IDDM asthma
DISEASE
and s/p CCY severalyears ago who presents from rehab w/ c/o RUQ abd
pain
DISEASE
x 3 days.Patient d/c from [**Hospital1 18**] [**2169-4-14**] following a right transmetatarsalamputation for
gangrenous
DISEASE
right foot. Patient's admission wasuncomplicated other than a
fever
DISEASE
spike on POD #1 o/n but CXRnegative and patient defervesced. She required 1 U PRBCintraoperatively for hct 26.8. Per daughter patient is somewhatconfused and currently an unreliable historian thus I relied onher daughter for hx. Her daughter states that her mom firststarted c/o diffuse
abdominal pain
DISEASE
but particularly subxiphoidal
abdominal pain
DISEASE
on Friday. Her mother states that the
pain
DISEASE
wasoccasionally worse w/ eating but her daughter states that hermom was eating a full liquid diet. She has been
vomiting
DISEASE
however. Occasionally it is the food she just ate and othertimes she will
vomit
DISEASE
up her pills. However she had soup andjello this am w/o
vomiting
DISEASE
. Her mom has also been c/o back
pain
DISEASE
but as far as her daughter can tell this is just her chronic
LBP
DISEASE
. She doesn't seem to relate the
pain
DISEASE
to her
abdominal pain
DISEASE
.Patient's daughter thinks her mom's last BM was on Friday butshe is really not sure. Per notes patient spiked temp of 101 atrehab. Patient's daughter is not aware of any h/o
PUD
DISEASE
or CAD inher mother. [**Name (NI) **] mom did have a
gall bladder
DISEASE
attack severealyears ago leading to CCY but o/w no abdominal surgeries/issues.Admission Date: [**2169-5-2**] Discharge Date: [**2169-5-10**]Date of Birth: [**2090-12-5**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 689**]Chief Complaint:
fever
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:pt is a 78 yo Spanish-speaking lady who presents w/
fevers
DISEASE
and
lethargy
DISEASE
. She is s/p was admit at [**Hospital1 18**] [**Date range (2) 1799**] c/b
adrenal insufficiency
DISEASE
(cortisol 1.1) bilateral adrenal masses
urosepsis
DISEASE
. She was briefly on pressors and was noted to have a RMTA
cellulitis
DISEASE
as well. She is s/p right transmetatarsalamputation [**3-25**] by [**Month/Year (2) 1106**] surgery and is planned for electiveR BKA once her medical condition stabalizes. On day of thisadmission pt was noted to have
fevers
DISEASE
and
lethargy
DISEASE
at herrehab was Admission Date: [**2149-6-2**] Discharge Date: [**2149-6-5**]Date of Birth: [**2081-3-23**] Sex: MService:CHIEF COMPLAINT: Left lower lobe pneumococcal
pneumonia
DISEASE
congestive heart failure
DISEASE
.HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 1968**] is a 68-year-old whitemale with a history of CAD status post three vessel CABG EFless than 20% mild
COPD hypertension
DISEASE
history of head and
neck cancer
DISEASE
history of
Hodgkin's disease
DISEASE
status postresection in [**2144**] in remission who presents with left sided
chest pain
DISEASE
worsening
dyspnea
DISEASE
on exertion shortness ofbreath and
cough
DISEASE
. Roughly two months ago the patient wasstill able to walk about one mile without problems howeverin the last month he has started to notice increasing
fatigue
DISEASE
and
dyspnea
DISEASE
on exertion. Three weeks ago he began coughingwith
fevers
DISEASE
up to 101 and mild
chills
DISEASE
intermittently. In thelast two weeks he has also noted increased sneezing andsevere non productive
cough
DISEASE
. Two days ago he developed[**2158-1-26**] constant stabbing
chest pain
DISEASE
under the left breastpleuritic in nature worse with
cough
DISEASE
and unresponsive toNitroglycerin. It was also worse with walking. His episodesof
pain
DISEASE
occur approximately one hour at a time and he doesexperience
shortness of breath
DISEASE
but no
nausea vomiting
DISEASE
diaphoresis
DISEASE
or radiation. The patient denies
headaches
DISEASE
neckstiffness sore throat
abdominal pain myalgias arthralgias
DISEASE
and
dysuria
DISEASE
. He has never been intubated. He does not havea history of
pneumonia
DISEASE
. In the Emergency Room he wastachypneic into the 30's initially satting 77%. He was thenplaced on a partial non rebreather mask at 15 liters and wasnoted to sat in the low 90's. He was given 40 mg of IV Lasixand diuresed about 150 cc of urine. Chest x-ray obtained inthe AW showed mild
failure
DISEASE
and a retrocardiac
opacity
DISEASE
. Hereceived 325 mg of Aspirin. Blood cultures times two wereobtained and he was given one dose of Levofloxacin. Hisinitial ABG was as follows: 7.49/32/38.PHYSICAL EXAMINATION: On admission vital signs temperature103.0 (rectal) pulse 109 blood pressure 98/44 respiratoryrate 26 O2 saturation 96% on 15 liters partial nonrebreather mask. General alert and oriented times threepleasant in mild
respiratory distress
DISEASE
with face mask on buttalking in full sentences. HEENT: Pupils were equal roundand reactive to light
extraocular movements
DISEASE
intactoropharynx was
dry
DISEASE
. There is
fullness of the neck
DISEASE
but no
lymphadenopathy
DISEASE
. Heart normal S1 and normal S2 no S3 nomurmurs or rubs. PMI non displaced. Lungs bronchial breathsounds bibasilarly left greater than right. No rales.Abdominal obese soft nontender non distended normoactivebowel sounds no
CVA tenderness
DISEASE
. Extremities 1Admission Date: [**2127-7-21**] Discharge Date: [**2127-7-30**]Service: MED
Allergies
DISEASE
:Bactrim / Amiodarone / Quinine / Codeine / ZithromaxAttending:[**First Name3 (LF) 898**]Chief Complaint:Abdominal DiscomfortMajor Surgical or Invasive Procedure:ERCP x 2Endotracheal IntubationHistory of Present Illness:The patient is an 85 year old woman with PMH of
ESRD
DISEASE
on HD
HTN
DISEASE
and DM who presented to the [**Hospital1 18**] ED on [**7-21**] with
complaint
DISEASE
of
nausea vomiting abdominal pain
DISEASE
and
diarrhea
DISEASE
x 3 days. Thepatient also reported recent
fever
DISEASE
and
chills
DISEASE
. In the EDpatient had a low grade temperature of 100.5 degrees. Herabdomen was slightly distended with no
rigidity
DISEASE
or rebound.Admission laboratory data were notable for WBC 6.2 elevatedtransaminases and INR 3.7. Right upper quadrant ultrasounddisclosed a 5 mm
gallstone
DISEASE
in the neck of the gallbladder.There was also a 5mm gallstone in the common bile duct withoutductal dilatation. The patient was evaluated by surgery for her
choledocholithiasis
DISEASE
. The patient was also seen by the ERCPfellow. The patient was not acutely ill last night so she wasadmitted to the Medicine team with plan for ERCP today. She waskept NPO and was administered IVF overnight. This morning she was administered 4 U FFP to reverse her INR. After receiving 2 U FFP she became hypoxic with O2 satsdropping to the 70s. She was placed on 100%
NRB
DISEASE
withimprovement in her O2 sats to the 90s. Prior to dialysis shewas given 100 mg IV Lasix with urine output (non measured). At1:50 PM she was transferred to the Hemodialysis Unit forinitiation of hemodialysis. Approximately 1 L was removed yetthe patient remained in
respiratory distress
DISEASE
with O2 sats inthe low 90s on
NRB
DISEASE
. At 2:30 PM a respiratory code was calledsince patient's O2 sats dropped to 70s on the NRB. The patientwas emergently intubated. ABG prior to intubation was7.21/55/55. EKG disclosed new ST segment depressions in theinferior and lateral leads. Following intubation the patient'sSBP dropped to 80s. She was administered approximately 500 ccNS bolus and required Dopamine transiently. The patient wastransferred to the MICU for further management.Past Medical History:1. End stage
renal disease
DISEASE
on hemodialysis via RIJ tunnelledportacath. h/o failed left arm
fistula
DISEASE
.2. History of
crescente glomerulonephritis
DISEASE
by renal biopsylikely related to underlying
vasculitis
DISEASE
.3.
Vasculitis
DISEASE
ANCA positive treated with chronic steroids.Currently on steroid taper.4.
Chronic obstructive pulmonary disease
DISEASE
.5. Steroid induced
diabetes mellitus
DISEASE
.6. Chronic
anemia
DISEASE
related to
end stage renal disease
DISEASE
.7. History of hemorrhoids.8.
Atrial fibrillation
DISEASE
status post transesophagealechocardiography and cardioversion currently on Atenolol andCoumadin with an ejection fraction of over 55 percent onechocardiogram in [**2126-3-2**].9.
Gastroesophageal reflux disease
DISEASE
with a normal EGD [**2126-6-2**].10.
Hypothyroidism
DISEASE
.11.
Hypertension
DISEASE
.Social History:Prior tobacco history over twenty years ago. She denies anyalcohol use. Shelives with her daughter [**Name (NI) **] [**Name (NI) 46**] who is her healthcare proxy. The patient is full code. Primary care physician is[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**].Family History:Non-contributoryPhysical Exam:General: Elderly female lying in bed ETT in place.VS: T: 100.7 BP: 104/48 initially 68/34 at 4 PM HR: 128 Resp: AC 550x14/100%/5 O2sat: 95%HEENT:
Sclerae
DISEASE
anicteric. PERRL. MMM. OP clear.Neck: Obese. Supple. Difficult to assess JVP.CVS: RRR. S1 S2. No m/r/g.Lungs: Crackles in bases bilaterally.Abd: Slightly distended. Admission Date: [**2149-9-2**] Discharge Date:Date of Birth: [**2081-3-23**] Sex: MService:CHIEF COMPLAINT: Shortness of
breath cough
DISEASE
increased
dyspnea
DISEASE
on exertion.HISTORY OF PRESENT ILLNESS: This is a 68 year old male witha history of
congestive heart failure
DISEASE
and an ejectionfraction of 30 to 40% status post three vessel coronaryartery bypass graft likely chronic obstructive pulmonarydisease and a [**2149-5-25**] admission for pansensitiveStreptococcus pneumococcal
pneumonia
DISEASE
who presented yesterdaywith
shortness of breath
DISEASE
for two days a
cough
DISEASE
productive ofwhite sputum
chills
DISEASE
and increased
dyspnea
DISEASE
on exertion. Thepatient was in his usual state of health able to walk Admission Date: [**2193-1-8**] Discharge Date: [**2193-1-18**]Date of Birth: [**2141-12-5**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 602**]Chief Complaint:
catatonia
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:51M w/ hx of
depression
DISEASE
remote
suicide
DISEASE
attempts and
OCD
DISEASE
presented to ED on [**1-8**] with c/o being nonconversant. He wasbeing weaned off abilify over the past 3 weeks due toAdmission Date: [**2133-9-3**] Discharge Date: [**2133-9-13**]Service: MEDICINE
Allergies
DISEASE
:Codeine / PenicillinsAttending:[**First Name3 (LF) 1974**]Chief Complaint:Left arm
pain
DISEASE
Major Surgical or Invasive Procedure:Bone biopsy--left humerusHistory of Present Illness:82M with h/o prostate CA who p/w increasing
pain
DISEASE
of left arm.Sveral months PTA pt hit his arm. He went to local ER and wastold he had a mild
fracture
DISEASE
treated with sling and
pain
DISEASE
control. however the
pain
DISEASE
worsened over the last few months.Pt came in to [**Hospital1 18**] for further evaluation. In [**Name (NI) **] pt noted tohave displaced
left humerus fracture
DISEASE
likely pathologic. ROS ofnotable for increased LE
edema
DISEASE
.Past Medical History:Prostate CA s/p resection unknown statusCAD s/p CABG x 4 in [**2123**] with no further caths per familyVfib arrest s/p ICD placement with 2 subsequent firings
CHF
DISEASE
unknown EF% followed by Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) 3236**] at [**Hospital1 3793**] Hospital (cards)
Afib
DISEASE
s/p pacemaker
hypercholesterolemia
DISEASE
glaucoma
DISEASE
Social History:Lives at home with son and daughter heavily involved in care.Tob: 1 ppd x many years quit 6y agoEtoh: noneIllicits: noneFamily History:non contributoryPhysical Exam:TAdmission Date: [**2103-8-16**] Discharge Date: [**2103-8-19**]Date of Birth: [**2070-11-24**] Sex: MService:CHIEF COMPLAINT: Cough and
shortness of breath
DISEASE
.HISTORY OF PRESENT ILLNESS: This is a 32 year-old male witha history of
Down Syndrome autism
DISEASE
and [**2097**]
pneumonia
DISEASE
complicated with
ARDS
DISEASE
who presents with one day of productive
cough
DISEASE
and low grade
fever
DISEASE
as well as yellowish nasaldischarge for the past few days. The patient was prescribedDoxycycline outpatient and took only two tablets beforerefusing to take anymore. He then became short of breath.The patient has had some
fatigue
DISEASE
and
anorexia
DISEASE
for the pastcouple of days.REVIEW OF SYSTEMS: No
nausea vomiting abdominal pain
DISEASE
or
diarrhea
DISEASE
. The patient generally gets an
infection
DISEASE
once everytwo to three months especially
infection
DISEASE
of the sinuseswhich is treated with Amoxicillin. He is hospitalized backin [**10-3**] to [**2098-11-4**] for similar symptoms which progressedto
ARDS
DISEASE
. At that time he was treated with CefuroximeClindamycin and Erythromycin. He was intubated at that timefor 27 days. In the Emergency Room his saturation was low tomid 90s on 80% on room air and 94 to 95% on a nonrebreather.ALLERGIES: Haldol prolonged QT benzodiazepines andnarcotics positive to severe
hypertension
DISEASE
.MEDICATIONS AT HOME: None.PAST MEDICAL HISTORY: Cataracts bilaterally status postsurgery. Downs and
autism
DISEASE
with mental age level of 4 yearsold recurrent
sinusitis
DISEASE
. History of
pneumonia
DISEASE
in [**2097**]complicated by ARDS. [**2099**]
tetanus
DISEASE
and pneumovax vaccinationwith a negative PPD at that time.SOCIAL HISTORY: He does not smoke or drink. He lives withhis parents.FAMILY HISTORY: Noncontributory.PHYSICAL EXAMINATION ON ADMISSION: Pulse 119. Bloodpressure 113/61. Respiratory rate 24. Temperature 103. 94%on a nonrebreather. Generally this is an agitated male whois breathing with much effort. HEENT pupils are equalround and reactive to light and accommodation. Extraocularmovements intact. Mucous membranes are dry. Oropharynx isdifficult to examine. There is no
sinus tenderness
DISEASE
. Neck issupple. Chest there are rhonchi bilaterally. No wheezes orcrackles noted. There is some nasal flaring and use ofabdominal muscles to breath. Cardiovascular regular rate andrhythm. Normal S1 and S2. No murmurs rubs or gallops.Abdomen is soft obese which is nontender with decreasedbowel sounds. Extremities no
clubbing cyanosis
DISEASE
or
edema
DISEASE
.LABORATORIES ON ADMISSION: White blood cell count 5.7 79.3%neutrophils 10.6% lymphocytes 7.5% monocytes 0.6%eosinophils and 2% basophils. Hemoglobin is 14.3 hematocrit42.1 platelet 208 sodium 144 potassium 4.7 chloride 103bicarb 31 BUN 17 creatinine 1.4 glucose 128 INR 1.3 PTT28.8. Chest x-ray on [**8-15**] shows no signs of
pneumonia
DISEASE
andchest x-ray on [**8-16**] showed prominent pulmonary vasculature.Blood cultures are pending. Arterial blood gas which ispolyvenous had a pH of 7.33 PCO2 60 PO2 48% and this isdone while on 85% on room air.HOSPITAL COURSE: 1. Respiratory: The patient had
hypoxia
DISEASE
and probable
hypercarbic respiratory failure
DISEASE
secondary to
tracheal bronchitis
DISEASE
and mucous plugging. The patient wastreated with antibiotics and given Albuterol Atroventnebulizer to improve the breathing. He was given anonrebreather but could not tolerate it. The patient wasswitched over to 8 liters of oxygen on nasal cannula. Thepatient then was able tolerate the nonrebreather for a coupleof hours before needing to switch over to a simple mask. Thepatient began to have low oxygen saturations and requiredintubation. However the patient's family decided to havehis code status switched from full code to DNR/DNI so thepatient was not intubated. The patient became progressivelymore hypoxic until he expired. On the second day ofhospitalization the patient's respiratory distress wasfurther complicated with mucous plugging that caused rightupper lobe collapse.2. Cardiovascular: The patient was tachycardic uponadmission secondary to
dehydration
DISEASE
so he was given 125 cc anhour of D5 half normal saline. His
tachycardia
DISEASE
did resolvetransiently until he became quite anxious in the IntensiveCare Unit. He then became tachycardic secondary to
anxiety
DISEASE
.3. Renal: He had some
prerenal azotemia
DISEASE
due to
dehydration
DISEASE
with a creatinine of 1.4. We did hydrate him with D5 halfnormal saline.4. Infectious disease: In regards to tracheal
bronchitis
DISEASE
he was given empiric treatment with Levaquin 500 mgintravenous q.d. and Ceftriaxone 1 gram intravenous q.d.However his right middle lobe
opacity
DISEASE
did not improve. Thepatient also had
sinusitis
DISEASE
which was treated with theantibiotics saline nasal spray and a 45 degree bed position.On [**2103-8-19**] Mr. [**Known firstname **] [**Known lastname 3794**] expired at 9:05 a.m. due to
respiratory arrest
DISEASE
secondary to
pneumonia
DISEASE
and lung collapsethat is secondary to mucous plugging. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 3795**]Dictated By:[**Last Name (NamePattern1) 3796**]MEDQUIST36D: [**2103-8-21**] 16:57T: [**2103-8-27**] 10:25JOB#: [**Job Number 3797**]Admission Date: [**2157-9-26**] Discharge Date: [**2157-10-3**]Date of Birth: [**2092-5-20**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Thiopental SodiumAttending:[**First Name3 (LF) 1283**]Chief Complaint:
Dyspnea
DISEASE
on exertionMajor Surgical or Invasive Procedure:[**2157-9-26**] Coronary Artery Bypass Graft x 5 (LIMA to LAD SVG toDiag SVG to OM1 to OM2 SVG to PDA)History of Present Illness:65 y/o male with PMH of CAD s/p MI in [**2147**] and [**2152**]. Recentlyc/o DOE and underwent an ETT which showed a perfusion defect.Underwent Cardiac cath which revealed severe three vesseldisease and referred for surgical intervention.Past Medical History:
Myocardial Infarction
DISEASE
[**2147**]/[**2152**]
Hypertension
DISEASE
Hypercholesterolemia Diabetes Mellitus Obesity
DISEASE
h/o Bladder
cancer
DISEASE
Social History:Active smoker with approx. 1.5ppd x 40yrs. Denies ETOH use.Family History:Father with MI in 80's Brother with MI at 67.Physical Exam:VS: 58 14 160/90Gen: WDWN male in NADSkin: w/d mult. nevi on torsoHEENT: NCAT EOMI PERRL OP benign with poor dentitianNeck: Supple FROM -carotid bruitChest: CTAB -w/r/rHeart: RRR -c/r/m/gAbd: Soft
NT/ND
DISEASE
Admission Date: [**2196-4-27**] Discharge Date: [**2196-5-1**]Date of Birth: [**2136-3-15**] Sex: FService: General SurgeryHISTORY OF PRESENT ILLNESS: This is a 60-year-old woman withclass III morbid
obesity
DISEASE
with a body mass index of 66.9 whohas tried and failed numerous
weight loss
DISEASE
programs. Shepresents now to the Gastric [**Hospital 3798**] Clinic for the evaluationof gastric restrictive surgery.PAST MEDICAL HISTORY: 1. Obstructive
sleep apnea
DISEASE
. 2. Hypertension. 3. Dyslipidemia. 4.
Gastroesophageal reflux disease
DISEASE
. 5. Cholelithiasis. 6. Osteoarthritis. 7. Chronic low back pain. 8. Fibromyalgia. 9. Diverticulosis.10. Hemorrhoids.11. Recurrent
panniculitis
DISEASE
.PAST SURGICAL HISTORY: Past surgical history is significantfor exploratory laparotomy hysterectomy and bilateralsalpingo-oophorectomy in [**2183**] for benign disease. She isstatus post supraclavicular node biopsy in [**2181**]. She isstatus post paniculectomy in [**2189**] complicated by developmentof a
seroma
DISEASE
.MEDICATIONS ON ADMISSION: Medications include ZestrilCardizem hydrochlorothiazide potassium Zoloft PremarinCelebrex albuterol inhaler multivitamin and aspirin.ALLERGIES: No known
drug allergies
DISEASE
.HOSPITAL COURSE: The patient was admitted to the GeneralSurgery Service on [**4-27**] and underwent an uncomplicatedopen gastric bypass surgery with open cholecystectomy.The patient's postoperative course was notable for persistent
hypotension
DISEASE
with stout pressure in the 80s requiring fluidboluses in order to maintain appropriate pressure and urineoutput. An electrocardiogram was obtained and the was ruledout for a
myocardial infarction
DISEASE
.She spent the following day in the Intensive Care Unit whereshe was closely hemodynamically monitored. She subsequentlycame out of the unit on postoperative day three and had arelatively benign remainder of her hospital stay.On postoperative day two she underwent a transesophagealechocardiogram that demonstrated decreased left atrialvelocities but no other abnormalities.She remained afebrile and on postoperative three wasrestarted on her hydrochlorothiazide. Her intravenous fluidswere
hep-locked
DISEASE
and her diet was advanced to a stage II.Her patient-controlled analgesia was discontinued and shewas initiated on oral
pain
DISEASE
medications which controlled her
pain
DISEASE
adequately.By postoperative four the patient was tolerating a stage IIdiet was passing gas and was advanced to a stage III diet.Her Foley had been discontinued midnight the night beforeand she was voiding without difficulty. Per therecommendations of the Electrophysiology fellow the patientwas initiated on Coumadin for her new onset of atrial
fibrillation
DISEASE
.DISCHARGE STATUS: The patient was subsequently discharged tohome.CONDITION AT DISCHARGE: In stable condition.DISCHARGE FOLLOWUP: Instructions to follow up with herprimary care physician to manage her outpatient Coumadindosing.MEDICATIONS ON DISCHARGE: (Medications at the time ofdischarge included) 1. Coumadin 2.5 mg p.o. q.d. 2. Atenolol 25 mg p.o. q.d. 3. Zestril 20 mg p.o. b.i.d. 4. Premarin 0.625 mg p.o. q.d. 5. Celebrex. 6. Hydrochlorothiazide 25 mg p.o. q.d. 7. Potassium chloride 10 mEq p.o. q.d. 8. Procardia. 9. Roxicet elixir 5 cc to 10 cc p.o. q.4-6h. p.r.n. for
pain
DISEASE
.10. Zantac elixir 150 mg p.o. q.d.11. Multivitamin.12. Vitamin B12. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**] M.D. [**MD Number(1) 3800**]Dictated By:[**Last Name (NamePattern1) 3801**]MEDQUIST36D: [**2196-5-17**] 15:14T: [**2196-5-18**] 08:42JOB#: [**Job Number 3802**]Admission Date: [**2113-5-10**] Discharge Date: [**2113-5-14**]Date of Birth: [**2035-11-8**] Sex: MService:HISTORY OF PRESENT ILLNESS: This is a 77 year old gentlemanwith past medical history of
asthma
DISEASE
recent Group A
Streptococcus non-necrotizing fasciitis
DISEASE
Dr. [**Last Name (STitle) **] for hisrecent
infection
DISEASE
the day of admission. At the appointment Dr.[**Last Name (STitle) **] noted that the patient had a significant cardiac rub. Achest x-ray was ordered which documented that there wassignificant
cardiomegaly
DISEASE
compared to his previous chest x-ray oneweek prior to admission. Dr. [**Last Name (STitle) **] referred the patient tothe [**Hospital6 256**] Emergency Department forechocardiogram to evaluate for a possible
pericardial effusion
DISEASE
.In the Emergency Department the patient was noted to havesignificant accumulation of pericardial fluid andphysiological evidence of
cardiac tamponade
DISEASE
. The patient wasadmitted from the Emergency Department to the CardiacIntensive Care Unit for hemodynamic monitoring. Thecardiology fellow was consulted regarding the need for
pericardiocentesis
DISEASE
. Given the patient's blood pressure wasstable the decision was made to hold off on
pericardiocentesis
DISEASE
until the morning following admission so the patient could havethe full attention of all members of the Cardiac CatheterizationLaboratory.PAST MEDICAL HISTORY:1. Asthma.2. Gout.3. Gastroesophageal reflux disease.4. Mild
anemia
DISEASE
.MEDICATIONS ON ADMISSION:1. Amoxicillin 500 q. 8 hours.2. Singulair.3. Albuterol.4. Salmeterol.5. Fosamax 70 q. Tuesday.6. Calcium with Vitamin D.
7. Fluticasone.PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.1 heartrate 55 blood pressure 151/56 respiratory rate 22 oxygensaturation 98% on room air. In general she was awell-appearing elderly male in no apparent distress. Headeyes ears nose and throat was anicteric. Facial muscleswere symmetric. Mucous membranes were moist.
Cardiovascular borderline tachycardia
DISEASE
notable soft
vocal-like
DISEASE
rub at the left lower sternal border. The patienthad a pulsus paradoxus at 22. Pulmonary the patient wasnoted to have basilar crackles no
wheezes or rhonchi
DISEASE
. Theabdomen with
active bowel sounds soft
DISEASE
nontender. Thepatient had mild mid
epigastric tenderness
DISEASE
as well as rightupper quadrant tenderness. There was no apparent guardingno rebound no evidence of acute abdomen. Extremities hehad mild 1Admission Date: [**2158-1-5**] Discharge Date: [**2158-1-9**]Date of Birth: [**2105-1-12**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 3814**]Chief Complaint:
DKA/Uremia
DISEASE
Major Surgical or Invasive Procedure:EGDHistory of Present Illness:52 yo man with DM 1 and triopathy as well as
PVD
DISEASE
and CRI(followed by transplant) p/w 3 days of
hyperglycemia
DISEASE
and
N/V
DISEASE
ofcoffee-ground
emesis
DISEASE
this am. Patient denies
infectious symptoms
DISEASE
or
cardiac symptoms
DISEASE
. Of note had a stress test 3 days ago readas normal. EKG in ED with lateral ST depressions and Admission Date: [**2137-4-23**] Discharge Date: [**2137-4-29**]Date of Birth: [**2090-12-9**] Sex: MService: CARDIOTHORCHIEF COMPLAINT: Aortic regurgitation.HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old malewith a history of
coronary artery disease
DISEASE
status post stentto left anterior descending. Subsequent to this procedurepatient developed
aortic regurgitation
DISEASE
. He was evaluated byCardiology and he underwent a catheterization on [**2137-4-9**] which showed
aortic regurgitation
DISEASE
4Admission Date: [**2110-1-6**] Discharge Date: [**2110-1-10**]Date of Birth: [**2046-5-20**] Sex: FService:ADMISSION DIAGNOSES:1. Rheumatic
heart disease
DISEASE
.2. Aortic and
mitral valve disease
DISEASE
.DISCHARGE DIAGNOSES:1. Aortic
valve stenosis
DISEASE
.2. Mitral
valve regurgitation
DISEASE
.3. Status post aortic valve replacement with 21 mmpericardial valve mitral valve repair with 28 mm [**Doctor Last Name 405**]annuloplasty band.HISTORY OF PRESENT ILLNESS: The patient is a 63 year oldwoman with a history of
rheumatic heart disease
DISEASE
. She hasknown
aortic and mitral valve disease
DISEASE
. Her lastechocardiogram was done on [**2109-12-12**] which revealed an ejectionfraction of 60%. Moderately severe
MR
DISEASE
[**First Name (Titles) 151**] [**Last Name (Titles) 3841**] enlargedLA were demonstrated as well as moderate to severe aorticstenosis with an estimated valve area of 0.9 cm squared.There was also significant
pulmonary hypertension
DISEASE
with PApressures estimated at 64 mmHg. Most recent ETT was negativein [**2105**] and performed for brief complaints of chestdiscomfort. Clinically patient reports that she is veryactive. She walks several miles a day cross country skiisand is able to cut and stack wood for her fireplace. Overthe past three weeks however she has noticed decrease inactivity tolerance along with
chest pain
DISEASE
and mild shortnessof breath that occurs with vigorous exertion. She reportsthat this discomfort can take up to several hours to resolve.She has never taken nitroglycerin. She is now referred forcardiac catheterization. Patient denies claudication
orthopnea edema
DISEASE
PND lightheadedness.PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia.Smoking history quit 20 years ago. Insulin dependent
diabetes mellitus
DISEASE
. Rheumatic
heart disease
DISEASE
. Autoimmune irondisease. Hypothyroidism. Osteoporosis. Bilateral carotidbruit without significant
carotid disease
DISEASE
.
Breast cancer
DISEASE
status post chemotherapy and surgery.PAST SURGICAL HISTORY: Status post left mastectomy in [**2086**].Cholecystectomy in [**2079**].MEDICATIONS ON ADMISSION: Miacalcin nasal spray Levoxyl 200mcg q.d. Lipitor 10 mg q.d. enalapril 5 mg q.d. Celebrex200 mg b.i.d. Protonix 40 mg q.d. folate 1 mg q.d. NPH 15units q.h.s. regular and Humalog insulin sliding scale.PHYSICAL EXAMINATION: In general the patient was an elderlywoman who appeared younger than her stated age and was in noacute distress. Vital signs were stable afebrile. Heightwas 5'2Admission Date: [**2131-12-23**] Discharge Date: [**2131-12-29**]Service: MEDICINE
Allergies
DISEASE
:Bactrim / Amiodarone / Quinine / Codeine / Zithromax /Lisinopril / Citalopram / Ciprofloxacin / HydralazineAttending:[**First Name3 (LF) 898**]Chief Complaint:Altered mental statusMajor Surgical or Invasive Procedure:IntubationPICC line placementHemodialysisTransfusion of one unit packed red blood cellsHistory of Present Illness:A [**Age over 90 **] year-old female with past medical history of chronic
obstructive pulmonary disease Wegener's granulomatosis
DISEASE
recentadmission [**Date range (1) 2374**] for acute on
chronic renal failure
DISEASE
with decision to initiate hemodialysis at that time and hospitalstay complicated by left lower lobe Moraxella pneumoniapresenting with altered mental status. Per her daughter thepatient was home this past week and accidentally took trazodone50 mg two days prior to admission which had been discontinueddue to
confusion
DISEASE
. Her confusion/visual
hallucinations
DISEASE
improvedthe day prior to admission. She complained of increasedproductive
cough
DISEASE
and oxygen requirement (previously intermittent2L NC now continuous) over the past two days responding to anincrease in nebulizer treatments. The patient was noted to belethargic this afternoon responsive to sternal rub. Whenaroused she was oriented x 3 and moving all extremities wellhowever. The patient was noted to be Admission Date: [**2191-4-8**] Discharge Date: [**2191-4-22**]Service: MICUHISTORY OF PRESENT ILLNESS: The patient is an 82-year-oldAfrican-American male with a known history of
prostate
cancer carcinoid syndrome
DISEASE
and
interstitial lung disease
DISEASE
secondary to asbestos exposure with an admitted in [**2190-2-21**] for
pneumonia
DISEASE
.At baseline the patient has
shortness of breath and dyspnea
DISEASE
on exertion. Two days prior to admission the patientbelieves that he acquired a cold because he subsequentlydeveloped a
cough
DISEASE
that was nonproductive. The patient hadmild
wheezing
DISEASE
and a temperature as high as 100.1 degrees oneday prior to admission. The patient's shortness of breathincreased with exertion and when lying flat. The patientstated that walking him Admission Date: [**2100-8-8**] Discharge Date: [**2100-8-12**]Date of Birth: [**2015-2-6**] Sex: MService: [**Year (4 digits) 662**]
Allergies
DISEASE
:ProcainamideAttending:[**First Name3 (LF) 3853**]Chief Complaint:Altered mental
status hypotension
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:85 yo M w/ PMH of bladder ca CAD
HTN
DISEASE
who is transferred fromOSH for concern for
urosepsis
DISEASE
. Pt presented to OSH day prior toadmission here with shaking
chills
DISEASE
and altered mental status. Ptreports he has had urinary incontinece over the past few dayswhich is abnormal for him denies any
dysuria
DISEASE
. He reportsawaking in the middle of the night with shaking
chills
DISEASE
and doesnot recall what else happed but that his girlfriend must havetaken him to the [**Name (NI) **]. ON arrival to the OSH he was
febrile
DISEASE
to103.3 and given 1 dose of tylenol. UA at the OSH was positivefor
UTI
DISEASE
. His BP dropped to 86/46 and he was given 3-4L of fluidswith improvement in BP to 101/48. They did a head CT forconcern of his altered mental status in the setting ofanticoagulation which was per report negative. He wastransferred here for further care given that this is where hehas all of his providers.On arrival to the [**Hospital1 18**] ED he was
febrile
DISEASE
at 102.5 rectally andwas given 650mg of tylenol. He was initially hemodyanmiallystable however his BP did drop down transiently into the 70sand he was given 2L bolus of fluid with good response in his BPand was stable in the 110s prior to transfer to the floor.Repeat blood and urine cultures were performed and he wasadmitted for possible
urosepsis
DISEASE
.On arrival to the MICU the patient is sleepy and complains ofsome chronic left sided
pain
DISEASE
. He denies any recent suprapubic
pain nausea vomiting flank pain
DISEASE
. He has not had a
UTI
DISEASE
since[**2091**] and he denies any
hematuria
DISEASE
or changes in his urine color.10 point ros is negative except per abovePast Medical History:-Recurrent bladder tumors- followed by Dr. [**Last Name (STitle) 3854**] recent urinecytology from cystoscopy on [**3-/2100**] showed clusters of highlyatypical urothelial cellssuspicious for
urothelial carcinoma
DISEASE
.-history of
prostatitis
DISEASE
dx at [**Hospital1 2025**]-ATRIAL FIBRILLATION - amiodarone /warfarin-CARPAL TUNNEL SYNDROME-CHOLELITHIASIS-CORONARY ARTERY DISEASE CABG in [**2070**]: SVG to LAD SVG to OM SVG to PDA cath in[**2086**] severe native disease occluded SVG to RCA and OM patentSVG to LAD redo CABG-HYPERTENSION-INGUINAL HERNIA-RENAL INSUFFICIENCYSocial History:Social History: lives alone in an apartment and has a servicethat he pays for were people can come help him if needed. Has ason and is in a long term relationship. 40pack year formersmoker quit years ago. Denies alcohol. Sings in acapella at[**Hospital **] rehabFamily History:NoncontributoryPhysical Exam:Admission Physical Exam:Vitals: 97.8 115/64 52 100% 2LGeneral: Alert oriented no acute distress sleepy in bedHEENT: Sclera anicteric MMM oropharynx clear EOMI PERRLNeck: supple JVP not elevated no LADCV: Bradycardic diastolic murmur at the LUSB not radiatingLungs: Clear to auscultation bilaterally no
wheezes rales
DISEASE
rhonchiAbdomen:
Protuberant soft non-tender non-distended bowel
DISEASE
sounds present no
organomegaly
DISEASE
no rebound or guardingGU: yellow urine in foleyExt: Warm well perfused 2Admission Date: [**2132-12-3**] Discharge Date: [**2132-10-1**]Date of Birth: [**2098-11-23**] Sex: MService:HOSPITAL COURSE: The patient is a 34 year old male statuspost motor vehicle accident on [**2132-7-9**] status posttalectomy on the right foot and bilateral ....... here for aright tibiocalcaneal fusion and a right iliac bone graft andinternal hardware placement.The patient tolerated the procedure well. On postoperativeday number one he had a maximum temperature of 101.5 thatspontaneously defervesced. He was maintained on intravenousantibiotics throughout the course of his stay. His incisionwas clean dry and intact.The patient was seen by physical therapy and after plainfilms were reviewed it was deemed appropriate to allow thepatient to have weightbearing as tolerated on the left lowerextremity with a walker boot in place and nonweightbearing onthe right ankle. He was discharged to rehabilitation on anAFO boot and is to follow up with Dr. [**Last Name (STitle) 284**] in twoweeks. Dr. ...... will be following him as an outpatientregarding his sciatic nerve issues.Dictated By:[**Name8 (MD) 4385**]MEDQUIST36D: [**2132-12-5**] 14:52T: [**2132-12-5**] 15:17JOB#: [**Job Number 4386**]Admission Date: [**2150-2-3**] Discharge Date: [**2150-2-16**]Service: CARDIOTHORACIC
Allergies
DISEASE
:Promethazine/CodeineAttending:[**First Name3 (LF) 1267**]Chief Complaint:
Chest pain
DISEASE
and
syncope
DISEASE
Major Surgical or Invasive Procedure:s/p AVR(19mm Mosaic porcine valve)/Aortic endarterctomy [**2-3**]s/p pacer placement [**2-10**]History of Present Illness:This 84WF presented to [**Hospital1 18**] [**Location (un) 620**] [**2150-1-19**] with CP and was inAF. She was treated with Lopressor and Dilt and became
asystolic
DISEASE
. She was resuscitated and transferred to [**Hospital1 18**]. Shewas found to have
aortic stenosis
DISEASE
and is now admitted for AVR.Past Medical History:
Aortic stenosis
DISEASE
recent
Afib
DISEASE
HTN
DISEASE
Pseudogout of R knee
Hypothyroidism
DISEASE
GERD EGD [**2144**]
Breast Cancer
DISEASE
[**2102**] s/p left mastectomys/p Hysterectomy
Osteoporosis
DISEASE
on EvistaAortic Stenosis
DJD
DISEASE
HandIron Deficiency
Anemia
DISEASE
[**2146**]Left Shoulder Impingement Syndrome
Spinal Stenosis
DISEASE
: MRI [**10-26**] showed severe
stenosis of spinal
canal and recesses at L4-L5
DISEASE
Osteoarthritis
DISEASE
: Right lower extremity
pain
DISEASE
and lower back painParonychia
Actinic keratosis
DISEASE
on R faceSocial History:Social history is significant for the absence of current tobaccouse. She previously smoked 1 ppd but quit 40 years ago. Thereis no history of
alcohol abuse
DISEASE
. She lives at home with aboarder.Family History:There is no family history of
premature coronary artery disease
DISEASE
or sudden death.Physical Exam:Elderly WF in NADAVSSHEENT: NC/AT oropharynx benignNeck: supple FROM no
lymphadenopathy
DISEASE
or thyromegaly carotids2Admission Date: [**2165-10-10**] Discharge Date: [**2165-10-16**]Date of Birth: [**2107-12-18**] Sex: MService: MEDICINE
Allergies
DISEASE
:IodineAttending:[**First Name3 (LF) 4393**]Chief Complaint:
Hyperkalemia
DISEASE
Major Surgical or Invasive Procedure:ParacentesisHistory of Present Illness:57 year old male with history of EtOH and HCV
cirrhosis
DISEASE
(genotype 1 treatment-naive) complicated by
ascites
DISEASE
hepatic
encephalopathy
DISEASE
with most recent EGD in [**2163**] showing no varicesas well as
seizure disorder polysubstance abuse
DISEASE
on methadonewith recent admission for
hepatic encephalopathy
DISEASE
now referredfrom his PCP's office for
hyperkalemia
DISEASE
and
acute renal failure
DISEASE
.He admits that he is often noncompliant with her medicationsand is almost completely reliant on his sister [**Name (NI) **] toadminister them (he can't even say which meds he's on).His last admission ([**9-13**] - [**2165-9-19**]) was notable for
hyponatremia hyperkalemia
DISEASE
acute
kidney injury
DISEASE
and
encephalopathy
DISEASE
. He underwent large volume paracentesis (4.7L)from which the peritoneal fluid grew GPCs and he was treatedwith vancomycin for 48 hours until cultures returned showing onebottle growing peptostreptococcus (believed to be acontaminant). Antibiotics were discontinued at that time and hehad no further signs of
infection
DISEASE
for the remainder of hishospital stay. His acute kidney injury was thought to be relatedto
hypovolemia
DISEASE
from overdiuresis improved with IV albumin. His
hyperkalemia
DISEASE
was treated with kayexylate and the
hyponatremia
DISEASE
improved with fluid restriction (132 on discharge). His hepatic
encephalopathy
DISEASE
resolved with lactlose. He was givenciprofloxacin 250mg daily for SBP prohpylaxis (given lowperitoneal fluid protein) and spironolactone was decreased from200 to 100mg Admission Date: [**2111-11-9**] Discharge Date:Service: Medical-[**Hospital1 **]ADMITTING DIAGNOSIS:
Pneumonia
DISEASE
.DISCHARGE DIAGNOSIS: MSSA line
infection
DISEASE
.CHIEF COMPLAINT: Right upper quadrant
pain
DISEASE
.HISTORY OF PRESENT ILLNESS: [**Known firstname **] [**Known lastname 4410**] is an 82-year-oldmale with history of
end stage renal disease
DISEASE
on hemodialysis
atrial fibrillation peptic ulcer disease hypertension SVT
DISEASE
and triple A who presented with right upper quadrant painright flank pain
nausea retching
DISEASE
and decreased appetite.Three days prior to admission after his routine dialysis henoted some shakes and later that day he noted some rightupper quadrant pain that was intermittent. Associatedsymptoms included right flank pain nausea retching anddecreased appetite with poor oral intake. The
pain
DISEASE
was notassociated with eating or position. He describes no previousepisodes that were similar to this. At his scheduleddialysis on the day of admission the dialysis center wasunable to access his catheter. Of note on [**2111-6-29**] he wasadmitted to [**Hospital1 2025**] for line
sepsis
DISEASE
with MSSA and treated withVanc and Gent and then switched to Nafcillin for 6 weeksdespite a TEE that was negative for
vegetation
DISEASE
.REVIEW OF SYSTEMS: Negative for
headache
DISEASE
visual changes
chest pain shortness of breath PND orthopnea diarrhea
DISEASE
change in color of
stool rashes
DISEASE
or skin changes. He doescomplain of
chronic constipation
DISEASE
and longstanding decreasedsensation in his lower extremities.PAST MEDICAL HISTORY: Hypertension BPH end stage renaldisease on hemodialysis
SVT
DISEASE
CVA
PVD
DISEASE
with severeclaudication in left leg status post left transmetatarsalamputation
gastritis
DISEASE
and
esophagitis atrial fibrillation
DISEASE
triple A 4.3 cm in 12/98 4.6 cm in 3/00 right inguinal
hernia GI bleed
DISEASE
[**2111-6-5**] while hospitalized at [**Hospital1 2025**] for line
sepsis
DISEASE
.ALLERGIES: No known
drug allergies
DISEASE
.MEDICATIONS: Amiodarone 200 mg q day Nephrocaps one mg qday Phos-Lo 667 mg three tablets tid TUMS 500 mg threetabs tid Percocet 2 tabs q h.s.FAMILY HISTORY:
Mother renal failure
DISEASE
. No
diabetes
DISEASE
hypertension
DISEASE
coronary
artery disease
DISEASE
or
cancer
DISEASE
.SOCIAL HISTORY: Positive for tobacco two packs per day for65 years occasional alcohol no drugs. He is a retired ironworker. He has three children and lives alone.PHYSICAL EXAMINATION: On admission temperature 99.0 pulse76 respirations 18 blood pressure 116/70 88% on room airto 93% on two liters. General lying in bed in no apparentdistress. HEENT: Pupils equal round and reactive to light
extraocular movements
DISEASE
intact. Oropharynx clear. Moist mucusmembranes. CV
quiet heart sounds
DISEASE
regular rate and rhythmno murmurs. Pulmonary clear to auscultation bilaterally.Abdomen soft non distended mild right upper quadrant
tenderness
DISEASE
to deep palpation no rubs or gallops normoactivebowel sounds. Back no
CVA tenderness
DISEASE
. Extremities no
edema
DISEASE
nontender left transmetatarsal amputation unable topalpate DP pulses bilaterally but feet were warm. Neuroalert and oriented times three
cranial nerves II
DISEASE
through XIIgrossly intact.LABORATORY DATA: White count 13.2 83 polys no bands 10lymphs 6 monos hematocrit 41.5 platelet count 182000 PT13.4 INR 1.3 PTT 30.2 sodium 141 potassium 5.2 chloride94 CO2 27 BUN 69 creatinine 10.5 glucose 87 bloodcultures were sent. Chest x-ray showed
cardiomegaly
DISEASE
andsmall bilateral
pleural effusions
DISEASE
septal line consistentwith mild
interstitial edema
DISEASE
. Cannot rule out left lowerlobe pneumonia. CT triple A measures 4.8 cm maximumunchanged from [**3-/2110**] no
appendicitis
DISEASE
or
diverticulitis
DISEASE
smallright
pleural effusion bibasilar consolidation gallstones
DISEASE
right inguinal hernia without
obstruction
DISEASE
or
strangulation
DISEASE
.HOSPITAL COURSE: While in the Emergency Room the patient'ssymptoms greatly improved. He was tolerating po in theEmergency Room. He had eaten a hamburger and has very little
pain
DISEASE
. The patient was admitted for further evaluation ofthis right upper quadrant
pain
DISEASE
. Blood culture quickly grewout gram positive cocci which later were found to be MSSA.The patient was started on Vanc 1 gm IV q day. On hospitalday #2 the patient began to complain of
dyspnea
DISEASE
and
pleuritic
DISEASE
chest pain
DISEASE
. He desatted to 87% on three liters which cameout to 90% on 100% non rebreather face mask. His temperaturewas 101.7. ABG showed PO2 of 72 PCO2 41 PH 7.9. The EKGshowed
atrial fibrillation
DISEASE
. He was given 2 mg of Morphinefor the
pain
DISEASE
and they attempted to wean the patient off thenon rebreather. However he became
hypotensive
DISEASE
with bloodpressure 80's/50's pulse 100-140. He began to becomesomnolent and did not respond to a 250 cc IV fluid bolus andwas transferred to the MICU. While in the ICU the antibioticcoverage was broadened to include Ceftriaxone and Flagyl.The patient's pressures were supported with Neo and thecatheter was changed to a right groin Quinton catheter. Thepatient was stabilized and transferred back to the floor onhospital day #4. On hospital day #5 a TTE was performed thatshowed a mildly dilated left atrium and a small mass orartifact seen on the aortic valve in the LV outflow tract.At this point the patient had grown out 6 bottles ofOxacillin sensitive staff. The patient's antibiotic coveragewas now changed to Oxacillin and Gentamycin. The goal wasOxacillin for six weeks and Gentamycin for two weeks.Throughout the stay the patient received hemodialysis threetimes a week without complications. On hospital day #8 arepeat chest x-ray was done that showed an increase in the
pleural effusion
DISEASE
on the right with an appearance ofloculation. After prolonged discussions with the patientthe patient declined to have the effusion tapped. Thepatient continued to have difficulty with access throughouthis stay and MR venogram was performed and the venogramshowed complete
SVC occlusion
DISEASE
above the azygous rightbrachiocephalic right subclavian and right IJ occlusion andpartial clot in the left brachiocephalic. At this time itwas felt that it was unlikely to be able to get a PICC linein the patient. So after discussion with
ID
DISEASE
antibioticcoverage was now going to be changed to Oxacillin while aninpatient and Vancomycin dosed at hemodialysis as anoutpatient again for total treatment of 6 weeks. Onhospital day #10 the patient developed
diarrhea
DISEASE
the
diarrhea
DISEASE
was non bloody had no
abdominal pain
DISEASE
it was sent for C.diff and as of hospital day 12 one sample had come backnegative. On hospital day #9 also the right groin Quintonwas removed without complication and on hospital day 11 atunneled groin cath was placed by IR. This tunneled groincath was to be used for hemodialysis only. Discussions withtransplant surgery were begun and the plan is for an AV
fistula
DISEASE
after completion of the antibiotics. Discussionswere also begun as to option for central access besides groinline. On hospital day #11 it was felt that the patient wasappropriate for acute rehab. He was seen by case managementand referrals were placed. The total antibiotic therapy wasstarted on [**11-12**] and the end date is [**12-23**]. He will receiveOxacillin while an inpatient which will be changed toVancomycin dosed at hemodialysis as an outpatient. [**Name6 (MD) 251**] [**Name8 (MD) **] M.D. [**MD Number(1) 910**]Dictated By:[**Last Name (NamePattern1) 4411**]MEDQUIST36D: [**2111-11-20**] 09:17T: [**2111-11-20**] 09:16JOB#: [**Job Number 4412**]Admission Date: [**2112-5-23**] Discharge Date: [**2112-5-27**]Service: ACOVEHISTORY OF PRESENT ILLNESS: This is an 83 year old malewith multiple medical problems including end-stage renaldisease on hemodialysis who had initially presented on [**5-23**]at Hemodialysis with decreased p.o. intake and one week of
cough
DISEASE
productive of clear sputum. In Hemodialysis thepatient was also noted to be rigoring at which time bloodcultures were drawn and the patient was subsequently senthome. At home the patient experienced generalized
weakness
DISEASE
and so presented to the Emergency Department.In the Emergency Department initial vital signs were atemperature of 103.0 F.Admission Date: [**2113-4-18**] Discharge Date: [**2113-5-2**]Service: MEDICAL/VASCULARCHIEF COMPLAINT: Left foot
cellulitis
DISEASE
.HISTORY OF PRESENT ILLNESS: This is an 83 year-old male withextensive past medical history sent from dialysis forevaluation and treatment who has been unable to walk or thepast eight months. He de
orthopnea
DISEASE
paroxysmal nocturnal
dyspnea fevers
DISEASE
or
chills nausea or vomiting
DISEASE
.PAST MEDICAL HISTORY: End stage
renal disease
DISEASE
onhemodialysis
hypertension
DISEASE
MSSA
sepsis
DISEASE
treated chronic
atrial fibrillation
DISEASE
history of
peptic ulcer disease
DISEASE
historyof
abdominal aortic aneurysm
DISEASE
history of benign prostatic
hypertrophy
DISEASE
history of
cerebrovascular accident
DISEASE
history of
peripheral vascular disease
DISEASE
history of gastrointestinalbleed history of
prostate carcinoma
DISEASE
. Left lower lobe
pneumonia
DISEASE
in [**2112-5-4**]. History of
gastritis
DISEASE
and
esophagitis
DISEASE
. History of right inguinal
hernia
DISEASE
withoutrepair.PAST SURGICAL HISTORY: Hemorrhoidectomy remote amputationof right first toe remote left
TMA
DISEASE
in [**2110-5-5**].ALLERGIES: No known
drug allergies
DISEASE
.MEDICATIONS ON ADMISSION:1. Levofloxacin 250 mg po q 48 hours.2. Flagyl 500 t.i.d.3. Colace.4. Senna tabs.5. Protonix.6. Zolpidem 5 mg q.d.7. Sevelamer 800 mg t.i.d.8. Nephrocaps one q.d.9. Amiodarone 200 mg po q.d.10. Coumadin 1 mg q.d.ADMISSION LABORATORIES: CBC with a white blood cell count of6.9 poly 72 lymphocytes 18 hematocrit 33 platelets 255BUN 9 creatinine 3.4 K 3.5. Echocardiogram done in[**Month (only) 956**] showed normal ejection fraction with
mitral
regurgitation
DISEASE
and
aortic regurgitation
DISEASE
noted.The patient was begun on Vanco Levo and Flagyl antibiotics.Coumadin was continued. Protonix was continued and vascularwas consulted regarding management. Vascular examinationshowed a pleasant male in no acute distress. HEENTexamination was unremarkable. carotids were without
bruits
DISEASE
.Heart was a regular rate and rhythm. The lungs werediminished at the right base and abdominal examination had apalpable
aortic aneurysm
DISEASE
. The foot examination showed a leftfoot cold with ischemic appearing black ulceration on theleft medial heel and ankle with no
erythema
DISEASE
fluctuance ordrainage. The pulse examination showed palpable femorals onthe right dopplerable on the left. Popliteal wasdopplerable on the right absent on the left. The dorsalispedis pulses were absent bilaterally. The patient PT wasdopplerable on the right and absent on the left. The footx-ray showed no evidence of
osteomyelitis
DISEASE
. Arteriogram on[**2113-3-30**] showed a
abdominal aortic aneurysm
DISEASE
with a left common
iliac aneurysm
DISEASE
with
plaque
DISEASE
. The distal superficial femoralartery popliteal and BK [**Doctor Last Name **] diseased the single vessel runoff via the peroneal was reconstituted to the dorsalis pedispulse. There was no posterior tibial pulse.Recommendations were to hold his Coumadin normalize his INRbegin heparinization for goal PTT between 40 and 60 obtainMRI/MRA of the left leg and the aorta to evaluate the aortaand in flow disease consider cardiac workup withechocardiogram and PMIBI continue antibiotics broadspectrum follow culture results and tailor as necessary.Multipodus splint to the right foot to prevent heelulcerations. Echocardiogram was obtained which demonstratedsymmetric left
ventricular hypertrophy
DISEASE
. This was asuboptimal technical quality study so focal wall motioncould not be excluded. The overall ventricular function EFwas greater then 55%. There was a mild
aortic stenosis
DISEASE
andmitral leaflets appeared thickened but they were unable toadequately assess the
mitral regurgitation
DISEASE
. There was mild
pulmonary hypertension
DISEASE
. Compared to previous study on[**2113-1-18**] there is probably a similar aortic gradient that isslightly higher. The patient underwent a PMIBI. There wereno
anginal
DISEASE
or ischemic changes but the patient did have
premature ventricular contractions
DISEASE
and premature atrialcontractions. His nuclear portion showed an abnormal studywith severe fixed defect involving the basilar portion of theinferior wall. The ejection fraction was calculated at 54%and on visual inspection it is in the range of 65 to 70.Medical attending evaluated the patient and a moderatecardiac risk for surgery. The patient had a CTA of theabdomen and pelvis to determine
abdominal aortic aneurysm
DISEASE
.Findings demonstrated
intrarenal abdominal aortic aneurysm
DISEASE
of4.9 by 5.2 cm. There is an
aneurysm
DISEASE
of the right proximalcommon iliac artery which measures 4.1 by 2.9 cm. There isan
aneurysm
DISEASE
of the left common iliac which measures 1.7 by2.5 cm. There is an
aneurysm
DISEASE
in the proximal right internaliliac artery which measures 1.4 to 2.0. There is dense
vascular calcification
DISEASE
and multiple venous collaterals seenalong the anterior subcutaneous tissues of the abdomen withcollateral flow to the right common femoral vein. There ismoderate stenosis of the right external iliac artery. The
celiac superior mesenteric arteries
DISEASE
are patent. There isdense
calcification
DISEASE
involving the ostium of the left renalartery and dense
calcifications
DISEASE
at the origin of the rightrenal artery. There are extensive venous intercostalcollaterals along the anterior abdominal wall. Thesefindings are consistent with severe
vena cava occlusion
DISEASE
. Theright inguinal
hernia
DISEASE
contains
small bowel
DISEASE
. There is noevidence of
obstruction
DISEASE
. Incidentally there was
gallstones
DISEASE
in the gallbladder. Bilateral
adrenal enlargement
DISEASE
mayrepresent
adrenal hyperplasia
DISEASE
. Diverticulosis withoutevidence of
diverticulitis
DISEASE
. The patient underwent anabdominal aortic angio with left leg run off. There showedsignificant
infrarenal aortic atherosclerotic
DISEASE
changes with
aneurysmal
DISEASE
dilatation extending to the common iliac. Thereis diffuse
atherosclerotic ulcerative plaque
DISEASE
of the bilateralexternal and internal iliac arteries. There is severedisease of the left superficial femoral artery whichoccluded at the adductor canal. The left PFA is occluded andabove and below knee popliteal arteries are occluded. Thereis reconstruction of a diffusely diseased attenuatedperoneal which reconstitutes the dorsalis pedis.After careful review of the arteriogram and CTA a longdiscussion with the patient's daughter and the patient wasdetermined being as a high risk and his comorbidities andrecommendations were a left below the knee amputation. Thepatient consented to that and underwent on [**2113-4-27**] a leftbelow the knee amputation. He tolerated the procedure welland he was transferred to the PAC in stable condition. Heremained hemodynamically stable. He was transferred to theVICU for continued monitoring and care. Initial dressing wasremoved on postoperative day number two. The wound wasclean
dry
DISEASE
and intact. The skin edges were intact with no
ecchymosis
DISEASE
and no drainage. Physical therapy andoccupational therapy began to work with the patient. renalcontinued to follow the patient for hemodialysis needs.Percocet caused the patient to be confused so he was startedon Tylenol #3. Renal recommended that the patient onlyreceive narcotics a single dose q 24 hours supplement thepatient's break through
pain
DISEASE
with extra strength Tylenoltablets two q 4 to 6 hours prn for
pain
DISEASE
. The remaininghospitalization was unremarkable. The patient was dischargedto rehab.DISCHARGE MEDICATIONS:1. Amiodarone 200 mg po q.d.2. Nephrocaps one q.d.3. Sevelamer 800 mg t.i.d.4. Protonix 40 mg po q.d.5. Acetaminophen 325 to 650 mg po q 4 to 6 hours prn for
pain
DISEASE
.6. Colace 100 mg b.i.d.7. Senna tablets one b.i.d.8. Metoprolol 25 mg b.i.d. hold for systolic blood pressureless then 100 heart rate less then 60.9. Albuterol Ipratropium multi dose inhaler one to two puffsq 6 hours.10. Coumadin 1 mg q.h.s.DISCHARGE DIAGNOSES:1. Severe
peripheral vascular disease
DISEASE
with left leg
ischemia
DISEASE
status post below the knee amputation.2. End stage
renal disease
DISEASE
on hemodialysis.3. PMIBI with fixed
inferior basilar wall defect
DISEASE
ejectionfraction greater then 55%. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 4417**]Dictated By:[**Last Name (NamePattern1) 1479**]MEDQUIST36D: [**2113-5-1**] 10:13T: [**2113-5-1**] 10:23JOB#: [**Job Number 4418**]Admission Date: [**2113-5-2**] Discharge Date: [**2113-5-5**]Service: MEDICINEHISTORY OF PRESENT ILLNESS: This is an 84-year-old man withmultiple medical problems including
end-stage renal disease
DISEASE
on hemodialysis previous
hypertension atrial fibrillation
DISEASE
peptic ulcer disease
DISEASE
recently status post left below theknee amputation from [**4-27**] and discharged from [**Hospital1 **] on [**5-1**] and was transferred to rehab.He returned to us on [**5-1**] because of increased
shortness of
breath
DISEASE
and
hypoxia
DISEASE
and was slightly obtunded. The patienthad dialysis on [**5-1**] and he was initially sating 96% on 2liters. In the Emergency Department he was given a dose ofceftriaxone and Levaquin for a
pneumonia
DISEASE
and left pleuraleffusion that was drained 800 cc of fluid.Postthoracentesis his saturations went up to 96-97%. He didhave a small
pneumothorax
DISEASE
as a complication of thisprocedure. However then his oxygen saturations fluctuatedin the low 90s. His blood pressure transiently dropped tosystolic blood pressure 75 which responded to fluid boluses.In the Emergency Department it was discussed with Renalthere was no need to dialyze at that time. He was evaluatedby Surgery for his left below the knee amputation whichappeared to be healing well as per Surgery.PAST MEDICAL HISTORY:1.
End-stage renal disease
DISEASE
on hemodialysis TuesdaysThursdays Saturdays.2.
Hypertension
DISEASE
.3.
Atrial fibrillation
DISEASE
.4.
Peptic ulcer disease
DISEASE
.5.
Abdominal aortic aneurysm
DISEASE
which is 4.3 cm in [**2108**].6. Benign
prostatic hypertrophy
DISEASE
with
prostate cancer
DISEASE
.7.
Cerebrovascular accident
DISEASE
.8.
Peripheral vascular disease
DISEASE
.9. Left below the knee amputation.10. History of MSSA line
sepsis
DISEASE
.11.
Gastritis
DISEASE
.12.
Esophagitis
DISEASE
.13. Right inguinal hernia.14.
Gastrointestinal bleed
DISEASE
in [**2111-6-5**].15. Chronic lower back pain.16. Previous admissions for persistent left lower loberetrocardiac
pneumonia
DISEASE
. CT scan in the past had shown amass. The patient on a previous admission had refusedbronchoscopy therefore the question of whether this
postobstructive pneumonia
DISEASE
was never worked up.MEDICATIONS ON ADMISSION:1. Amiodarone 200 mg q day.2. Nephrocaps one cap q day.3. Renagel of 800 mg tid.4. Protonix 40 mg q day.5. Colace 100 mg [**Hospital1 **].6. Coumadin 1 mg q day.7. Lopressor 25 mg [**Hospital1 **].8. Senna.SOCIAL HISTORY: He is a two pack per day smoker for 65years occasional alcohol use. He is a retired iron workerand lives alone.EXAMINATION ON ADMISSION: His temperature was 99.2 bloodpressure 102/45 heart rate 83 respiratory rate 18 andsating at 91% on 4 liters. In general he was awake. HisHEENT: Pupils are equal and reactive but were about 1 mmbilaterally.
Extraocular movements
DISEASE
are intact. Dry mucousmembranes. Chest: He had decreased breath sounds on theleft with
coarse breath sounds
DISEASE
on the right. Cardiac:Regular rate and rhythm with a
systolic murmur distant
DISEASE
heart sounds. Abdomen: Positive bowel sounds. Softnontender nondistended. Extremities: Left below the kneeamputation tender stump bandage right leg showed no
edema
DISEASE
with poor toenail care. Neurologic: Mental status: He wasawake and talks. Alert to person and [**Hospital1 **]and was speaking nonsense at times.LABORATORIES ON ADMISSION: Sodium of 140 potassium 5.9chloride 104 bicarb 21 BUN 38 creatinine 6.5 glucose 72nonhemolyzed specimen. His white count was 9.4 hematocritof 33.5 platelets of 200 83% neutrophils 13% lymphocytes.His INR was 1.5 with a PT of 14.8 and a PTT of 24.6. CK of4006 CK MB of 17 MBI was 0.4 and troponin of 1. Hispleural fluid showed protein 2.3 glucose 92 LDH 84 albuminof 1.3. His blood cultures were drawn.Electrocardiogram showed a junctional rhythm withquestionable ST
depressions
DISEASE
in V3 through V6 but appearsolder consistent with electrocardiogram on [**2113-4-19**]. Regularrate at 86 with some low voltages.Chest x-ray showed progression of a left
pleural effusion
DISEASE
with partial layering and the right
pleural effusion
DISEASE
appearedto be stable.The patient was initially admitted to the MICU from [**5-1**] to[**5-3**].1. Pulmonary: The patient presented with
shortness of breath
DISEASE
and
hypoxia
DISEASE
. Chest x-ray showed a large left pleuraleffusion which was much increased from his previous chestx-ray. His left effusion was tapped in the Emergency Room.His sats have been maintaining in the low 90s on anonrebreather given that the probability of a
pneumonia
DISEASE
andintermittent
hypertension
DISEASE
. Blood cultures were sent. Thiswas thought to be
sepsis
DISEASE
from a
pneumonia
DISEASE
. He was started onceftriaxone and Levaquin.His antibiotics were then changed to ceftazidime and wascontinued on Vancomycin since he had previously been on thisfor
colonization
DISEASE
by MRSA in his toes. Eventually his sputumcultures did grow out Staph coag positive species and hisceftazidime was then switched over to levofloxacin and Flagylpo on [**2113-5-4**].The possibility of
pulmonary embolus
DISEASE
was considered given his
hypotension
DISEASE
his
acute respiratory decompensation
DISEASE
andincreased left
pleural effusion
DISEASE
however the patient hassince refused CTA. Patient's saturations over the course ofthe hospitalization has remained approximately 94-95% on theMedical floor when he was transferred on [**2113-5-4**].2. Cardiovascular: The patient has a history of atrial
fibrillation hypertension
DISEASE
and
abdominal aortic aneurysm
DISEASE
.Given his new
hypotension
DISEASE
his blood pressure medicationswere held (his beta blocker was held). He was continued onamiodarone and was kept in regular rhythm. Hisanticoagulation he had been subtherapeutic as per records onhis last admission and had not been anticoagulated. He wasrefusing Heparin drip as well because he was refusing blooddraws and understood the risks and benefits of not being onHeparin and was restarted on Coumadin in hospital.His blood pressure has remained in the 85-100 rangetolerating ................ greater than 55.His last issue was his elevated CK MB and troponin. Hiselevated CK was thought to be secondary to his below the kneeamputation since his MB index was low thought to be secondaryto his
renal failure
DISEASE
. His enzymes were cycled and remainedstable. His CK continued to fall.3. Renal: Patient with
end-stage renal disease
DISEASE
onhemodialysis. He continued on hemodialysis on TuesdaysThursdays and Saturdays. He had some degree of
rhabdomyolysis
DISEASE
and the Renal team did not feel that therewas any urgent need for dialysis initially. He was continuedon Nephrocaps and Renagel.4. GI: Given his history of
peptic ulcer disease
DISEASE
and
gastrointestinal bleed
DISEASE
he was given Protonix. Hishematocrit had remained stable throughout hospitalizationand his vascular surgery had been following him for his leftbelow the knee amputation. He is stable from that standpointand has been having dressing changes as needed. He has amultipodas boot on the right foot that should be continuedgiven his
tenderness
DISEASE
on the right heel.His code status was changed in the hospital from full codefrom DNR/DNI. The patient has been refusing blood draws andunderstands the risks of refusing both the CTA of the chestand refusing blood draws.DISCHARGE DIAGNOSES:1. Left lower lobe
pneumonia
DISEASE
.2. Left
pleural effusion
DISEASE
status post thoracentesis with small
pneumothorax
DISEASE
.3.
Hypotension
DISEASE
.4.
Sepsis
DISEASE
.5. Paroxysmal
atrial fibrillation
DISEASE
.6.
End-stage renal disease
DISEASE
.MEDICATIONS AT DISCHARGE:1. Amiodarone 200 mg po q day.2. Aspirin 325 mg po q day.3. Combivent 1-2 puffs q6h.4. Renagel 800 mg po tid.5. Nephrocaps one cap po q day.6. Vancomycin dosed when Vancomycin level is less than 15 athemodialysis.7. Levofloxacin 250 mg po q48h starting on [**2115-5-7**].8. Flagyl 500 mg po tid to stop on [**5-14**].9. Coumadin 1 mg po q hs to be titrated for a goal of [**2-6**]INR.10. Protonix 40 mg po q day.11. Senna one tablet po bid prn.12. Colace 100 mg po bid.13. Folic acid 1 mg po q day.TREATMENTS: He is to continue on hemodialysis on TuesdaysThursdays Saturdays and to be monitored for his INR onCoumadin. He is to have dressing changes to the left belowthe knee amputation and to keep the left leg straight. Heis to followup with his primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]and he should also have multipodas boot to the right footwhile in bed sheepskin and Physical Therapy for his leftbelow the knee amputation. He is to be discharged to[**Hospital3 4419**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**] M.D. [**MD Number(1) 1212**]Dictated By:[**Name8 (MD) 1020**]MEDQUIST36D: [**2113-5-5**] 08:31T: [**2113-5-5**] 08:35JOB#: [**Job Number 4420**]Admission Date: [**2113-11-29**] Discharge Date: [**2113-12-2**]Date of Birth: [**2058-2-22**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4421**]Chief Complaint:
Nausea
DISEASE
and
Vomiting
DISEASE
.Major Surgical or Invasive Procedure:None.History of Present Illness:55 year-old female with recently diagnosed stage IIIA fallopiantube
adenocarcinoma
DISEASE
who presented to oncology clinic complainingof ongoing
nausea vomiting
DISEASE
and
weakness
DISEASE
. She received herfirst cycle of chemotherapy consisting of intravenous Taxol andcarboplatin on [**2113-11-1**] and last week received her second cycleconsisting of intravenous Taxol and intraperitoneal cisplatinfollowed by aggressive antiemetics with dolasetron Emend andcompazine. Ever since her recent chemotherapy she has had some
abdominal pain nausea vomiting
DISEASE
and was feeling tired. Shehas not been able to keep any food down but has been tying todrink Boost and Ensure as tolerated. She has not had any
diarrhea
DISEASE
. She describes also intermittent fevers/chills athome without any
headache
DISEASE
change in vision
chest pain
DISEASE
SOBexcessive thirst or
urination
DISEASE
or change in her bowel habits.In oncology clinic she was found to be dehydrated with a serumsodium in the 108 range and potassium in the low 2 range and isadmitted for further management..In the ED she was afebrile with normal vital signs and anormal mental status exam (per her husband). She was given IVnormal saline potassium replacement and was admitted to the[**Hospital Unit Name 153**] for further management. The patient's sodium improved withnormal saline. The etiology of her
hyponatremia
DISEASE
and
hypokalemia
DISEASE
was unclear but was possibly secondary to SIADH exacerbated by
dehydration
DISEASE
and electrolyte loss (
vomiting
DISEASE
) or secondary to acomponent of
Fanconi's syndrome
DISEASE
. Hypertonic saline anddemocycline were not necessary. The patient's cortisolstimulation test and TSH were within normal limits. Celexa wasdiscontinued due to its association with SIADH. The patient'sIVF were discontinued at noon the day of transfer to the OMEDfloor with sodium improving to 128 and normalization of herpotassium.Past Medical History:1. Stage IIIA grade III left-sided fallopian tube
cancer
DISEASE
statuspost total abdominal hysterectomy bilateral
salpingo-oophorectomy left pelvic lymph node dissection
DISEASE
peritoneal washings and omental biopsy on [**2113-10-10**].2.
Hypertension
DISEASE
3. Major
Depression
DISEASE
4. History of
gastrointestinal bleed
DISEASE
Social History:She lives in [**Doctor Last Name 792**]with husband and two of her threesons. [**Name (NI) **] husband is a cardiologist. She denies tobacco orEtOH use.Family History:NCPhysical Exam:VITAL SIGNS: 98 85 160/100 20 98%
RA
DISEASE
GENERAL: Pale female with
alopecia
DISEASE
tired-appearing in NADHEENT: MM
dry
DISEASE
with
cracked red lips anicteric no sinus
tenderness
DISEASE
NECK: Supple no LAD JVP flatHEART: RRR with a flow murmur no S3 or S4CHEST: Clear to ausculatation and percussion bilaterallyABDOMEN: Soft obese NT ND palpable IP port in LUQ without
erythema
DISEASE
EXTREMITIES: No c/c/e pale nail beds normal cap refillNEUROLOGIC: AAO x 3 appropriate CN intact strength 5/5 inbilateral upper and lower extremities. No sensory defect. Didnot assess gaitSKIN: Flushed erythematous apearance of neckMUSCULOSKELETAL: No joint effusions notedPertinent Results:[**2113-11-29**] 12:30PM SODIUM-108* POTASSIUM-2.0* CHLORIDE-65*[**2113-11-29**] 03:15PM GLUCOSE-175* UREA N-22* CREAT-1.0 SODIUM-109*POTASSIUM-2.8* CHLORIDE-66* TOTAL CO2-29 ANION GAP-17[**2113-11-29**] 03:25PM GLUCOSE-171* LACTATE-3.2* KAdmission Date: [**2189-12-1**] Discharge Date: [**2189-12-11**]Date of Birth: [**2123-2-13**] Sex: MService: VSUCHIEF COMPLAINT: Chronic right ankle
infection
DISEASE
with unstablejoint.HISTORY OF PRESENT ILLNESS: This is a 66-year-old male witha nonhealing right malleolar wound and
fracture
DISEASE
for the last2 years who underwent a right ankle traction and openreduction internal fixation. The patient has had multipleadmissions for wound
infections
DISEASE
and multiple IV antibioticcourses. Most recent admission was [**2189-9-28**] for awound
infection
DISEASE
. The patient recently complained of atemperature elevation on [**2189-11-30**] and now is to beadmitted to
Dr.[**Name
DISEASE
(NI) 1392**] service for continued IVantibiotics. The patient initially was discharged ondaptomycin and followed by VNA.PAST MEDICAL HISTORY: Type 2
diabetes
DISEASE
with
triopathy
DISEASE
endstage renal disease
DISEASE
secondary to
diabetes
DISEASE
status postcadaver transplant in [**2182**] history of coronary arterydisease status post CABG in [**2178**] history of peripheral
vascular disease
DISEASE
right ankle
fracture
DISEASE
in [**2188-6-6**] with anopen reduction internal fixation status post hardwareremoval
chronic osteomyelitis
DISEASE
.ALLERGIES: No known
drug allergies
DISEASE
.MEDICATIONS: Percocet dicloxacillin 100 mg twice a daygabapentin 1600 mg twice a day Lasix 20 mg twice a daySensipar 30 mg daily metoprolol 25 mg daily ranitidine 150mg daily. There are two other medications that the patient ison of which the handwriting is not decipherable at thistime.SOCIAL HISTORY: The patient is a nonsmoker is married andlives with his spouse.PHYSICAL EXAMINATION: Vital signs 94.6 94 18 bloodpressure 144/88 oxygen saturation 93% in room air. Bloodsugar fingerstick was 291 on admission. General appearance:Alert cooperative white male in no acute distress. HEENTexam: Mild right eye
ptosis
DISEASE
. Neck is supple without
lymphadenopathy
DISEASE
or
carotid bruits
DISEASE
. Lungs are clear toauscultation bilaterally. Chest is with a well healed mediansternotomy incision. Heart is a regular rate and rhythm witha
systolic ejection murmur II/VI nonradiating
DISEASE
. Abdomen issoft nontender obese. Extremities: Right malleolus withpunctate lesion with draining and surrounding
erythema
DISEASE
. Pulseexam shows palpable radial pulses femoral pulsesbilaterally. The right DP and PT are dopplerable signals. Theleft DP and PT are dopplerable signs. Neurological exam isnonfocal.HOSPITAL COURSE: The patient was admitted to the vascularservice. His dicloxacillin was continued. Vancomycin andFlagyl were instituted. He was continued on his preadmissionmedications. He was seen by Dr. [**Last Name (STitle) 1391**] and advisement wasmade for him to undergo a below the knee amputation. Thepatient accepted the recommendation. Transplant nephrologywas consulted to follow the patient during hishospitalization. [**Last Name (un) **] was consulted for hyperglycemicmanagement. Daily SK5 levels were obtained. He requiredminimal adjustment in his immunosuppression. He continued onhis Lantus with a Humalog sliding scale with improvement inhis glycemic control. On [**2189-12-3**] he underwent aright BKA without incident. He was transferred to the PACU instable condition. At the end of his surgical procedureintraoperatively the patient became
hypotensive
DISEASE
withsystolic blood pressure in the 60s and he was given Neo 200mcg x2 and epinephrine 5 mg x2. The patient went into amonomorphic VT 4 minutes at a rate of 130. He was givenlidocaine 100 mg IV bolus and amiodarone 125 mg over 15minutes. The patient converted to sinus rhythm. Anintraoperative TEE showed severe
biventricular failure
DISEASE
.Dopamine was started at 5 mcg/kg/minute. Blood pressureimproved. He was transferred to the PACU and then to the ICUfor continued care. Serial enzymes were obtained. Repeat echowas obtained on the 28th which demonstrated left ventricularwall thickness and cavity dimensions were obtained by 2-Dimages. He has severely
depressed left ventricular ejection
DISEASE
fraction. He had multiple regional
wall motion abnormalities
DISEASE
.His aortic valve was moderately thickened leaflets. Therewere no masses or
vegetations
DISEASE
on the aortic valve. No aortic
insufficiency
DISEASE
. The
mitral valve tricuspid valve
DISEASE
were normalwith trivial MR [**First Name (Titles) **] [**Last Name (Titles) **]. The pulmonic valve and artery wereunremarkable. The pericardium showed no
pleural effusion
DISEASE
.Aortic valve area was calculated at 1.3 cm squared normal is3 cm squared. Gradient peak was 32 mm. There was no
intracardiac thrombus
DISEASE
noted on the primary or the secondaryecho. The ejection fraction was calculated at 30% to 40%. IVheparin was begun to maintain a goal PTT between 40 and 60.The patient's Dobutamine was weaned with hopes to extubate.Pulse exam remained unchanged. The right amputation site wasclean dry dressing. He remained on bedrest in the SICU.Cardiac enzymes: Base was 20 peaked at 96 for the CK. CK MBswere not obtained. His troponins were 0.01 and 0.03. Thepatient's Swan was converted to a CVL on [**2189-12-4**].The patient continued on heparin was extubated andtransferred to the VICU for continued monitoring and care on[**2189-12-5**]. Cardiology was requested to see thepatient on [**2189-12-6**] who felt the patient washemodynamically stable and his
atrial fibrillation
DISEASE
was ratecontrolled. We should continue the heparin while his INR isless than 2 and his goal INR should be [**1-9**] and recommendmetoprolol tartrate twice a day versus single dosing. Theyrecommended aspirin 81 mg and simvastatin 20 mg daily.
Hyperglycemia
DISEASE
control remained relatively good. He did notrequire adjustment in his Lantus. His premeal coverage wasadjusted. Vancomycin ciprofloxacin and Flagyl werediscontinued on [**2189-12-7**]. The patient remainedafebrile. Foley was discontinued. Peripheral line was placedand the central line was discontinued. The patient had beenadvanced to a regular diet and ambulation to chair was begun.On [**2189-12-8**] postoperative day 5 the patientcontinues on IV heparin/Coumadinization conversion. Serialcoags were monitored. Physical therapy will see the patientand make recommendations regarding disposition planningbeing a new amputation if he will go to rehabilitation. Willtalk to
infectious disease
DISEASE
Dr. [**Last Name (STitle) 2379**] regarding discontinuethe doxycycline. The remaining hospital course the patientwill be discharged when medically stable and bed available atrehabilitation. At the time of discharge dischargemedication instructions will be dictated. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**] [**MD Number(1) 2381**]Dictated By:[**Last Name (NamePattern1) 2382**]MEDQUIST36D: [**2189-12-8**] 11:23:20T: [**2189-12-8**] 14:38:59Job#: [**Job Number 2383**]Admission Date: [**2178-11-12**] Discharge Date: [**2178-12-3**]Date of Birth: [**2112-4-25**] Sex: FService: MEDICINEHISTORY OF PRESENT ILLNESS: The patient is a 66-year-oldfemale who was initially admitted on [**2178-11-12**]complaining of increased
weakness
DISEASE
and
groin pain
DISEASE
since ninedays prior to admission when she had a fall. Since the fallthe patient had been basically confined to her bedroom didnot drink or eat and lived on some water coffee cigarettesand occasional beer. According to her family the patienthad been not very mobile for some time prior to admissionmostly because of severe
exertional dyspnea
DISEASE
. Howeverdespite her
dyspnea
DISEASE
she continued to smoke two packs ofcigarettes per day.On admission the patient denied any
fevers chills nausea
DISEASE
vomiting dizziness
DISEASE
chest pain
DISEASE
.PAST MEDICAL HISTORY: Significant for chronic obstructive
pulmonary disease
DISEASE
hypertension
DISEASE
history of vitamin B12deficiency.ALLERGIES: No known drug
allergies
DISEASE
.MEDICATIONS ON ADMISSION: Tiazac 240 per day Premarin0.625 mg per day Provera 2.5 mg per day clonazepam 1 mgthree times a day Atrovent two puffs four times a dayalbuterol four puffs four times a day Ventolin as needed.FAMILY HISTORY: Noncontributory.SOCIAL HISTORY: Lives alone lifelong smoker at least twopacks per day. Drinks ethanol on a regular basis.PHYSICAL EXAMINATION: On admission vital signs 97.7 bloodpressure 90/60 heart rate 101 respiratory rate 29 oxygensaturation 90% on 2 liters. In general she was alert andoriented x 3 very
cachectic
DISEASE
in no apparent distress. Herpupils were equal reactive responsive to light andaccommodation extraocular muscles were intact oropharynxwas clear. The skin was without rashes. The neck showed no
jugular venous distention
DISEASE
no
bruits
DISEASE
. The lungs showeddecreased air movement and were
wheezy
DISEASE
. Heart regular rateand rhythm plus murmur. The abdomen was soft nontenderwith normal
active bowel sounds
DISEASE
. Extremities were clear no
clubbing cyanosis
DISEASE
or
edema
DISEASE
good pulses distally.Neurological examination was nonfocal.LABORATORY DATA: On admission significant for a whiteblood cell count of 23.7 hematocrit 43.5 platelets 651.Liver function tests were normal. Chemistries were normal.Creatinine 0.5. Chest x-ray showed a right upper lobeinfiltrate. Hip films were suspicious for a left femoralneck
fracture
DISEASE
. Electrocardiogram showed
sinus tachycardia
DISEASE
.HOSPITAL COURSE: This is a 66-year-old female with severe
chronic obstructive pulmonary disease hypertension
DISEASE
whopresented with
right upper lobe pneumonia
DISEASE
and a possible lefthip
fracture
DISEASE
and generalized weakness. She is a long-timesmoker and has also had ethanol abuse on a regular basis.She was given intravenous fluids antibiotics levofloxacinintravenously nebulizer therapy inhalers and oxygen. Shewas put on ethanol and nicotine withdrawal precautions givendeep
venous thrombosis
DISEASE
prophylaxis and was seen byOrthopaedic Surgery consult. Orthopaedic service decided totreat her left hip
fracture
DISEASE
nonoperatively because it wasstable and impacted in an acceptable but not ideal position.Pinning the hip in that position would have been technicallydifficult and has drawbacks and because of her severe
chronic obstructive pulmonary disease
DISEASE
and
pneumonia
DISEASE
it wasdecided to avoid surgery. She was discontinued from herPremarin because this increases the risk of deep venous
thrombosis
DISEASE
. She would need to walk with a walker for four tosix more weeks for which she would need a rehabilitationhospital or home care with services.On [**11-15**] the patient was found to have oxygen saturations aslow as 53%. She was placed on 100% non-rebreather whichimproved her saturations to 100%. The patient was noted tohave a weak
cough
DISEASE
. Oral/nasal suctioning was started andthe patient was breathing better. Changed to 4 liters ofnasal cannula oxygen saturating 95%. However she continuedto be more somnolent and difficult to arouse. An arterialblood gas showed a pH of 7.3 PCO2 89 PO2 200 on 100%non-rebreather. Chest x-ray showed worsening right upperlobe
pneumonia
DISEASE
.The patient was transferred to the Medical Intensive CareUnit for further airway management. She did not tolerateBiPAP secondary to
depressed
DISEASE
mental status and secretionsand therefore was intubated for pulmonary toilet and moreadequate respiration to protect mental status.Later that day after a lengthy discussion with the son[**Name (NI) 1704**] and daughter [**Name (NI) **] it was learned that the patienthad been completely noncompliant with medical care prior toadmission. Her oldest daughter [**Name (NI) **] is her health careproxy but feels that [**Name (NI) 1704**] should be making the medicaldecision as Mrs. [**Known lastname 4427**] lives with him and is close to him.Mrs. [**Known lastname 4427**] had previously expressed to her primary carephysician that she wanted to have all medical interventionsbut no be on a breathing machine for a prolonged period oftime. Given her
acute decompensation
DISEASE
and
pneumonia
DISEASE
therewas reversible component to her situation however it wasexplained to them the severity of the underlying
lung disease
DISEASE
and the chance of prolonged intubation. [**Doctor First Name **] expressed thather mother has been severely
depressed
DISEASE
for the past 15 yearssince her husband and two children died and has beencommitting slow suicide by abusing her body with tobaccoethanol and caffeine. She has refused interventional therapyor medication. It was decided at that point that she wouldbe made Do Not Resuscitate but would continue on theventilator.The patient continued to be treated with Levaquin and Flagylfor possible aspiration
pneumonia
DISEASE
and was continued on therespirator but had a difficult time being weaned from theventilator. Chest x-ray showed emphysematous blebs in herleft lower lobe and continuing right
pleural effusion
DISEASE
thatlayered.By [**11-19**] her pressure support on the ventilator wasdecreased to 10 although she failed a spontaneous breathingtrial.
Pleural effusion
DISEASE
was stable acid fast bacillinegative x 3. She was evaluated by Nutrition and started ontube feeds Impact with fiber at 40 cc/hour.On [**11-20**] she had to be placed back on pressure support of 12and 5 because of
failure
DISEASE
to tolerate the lower pressures.Plans were made on that day for percutaneous tracheostomy ifshe continued to fail her wean. She was treated for eightout of 21 days with levofloxacin and eight of 14 days withFlagyl.She continued to demonstrate difficulties in weaning from theventilator. Atrovent was added on [**11-22**] and she wascontinued on her antibiotics.On [**11-21**] it was discussed with the family and it was decidedthat it would be attempted to avoid tracheostomy and attemptventilatory wean because the wishes of the patient and thefamily were to not have long-term intubation on atracheostomy and that she would not want to be reintubated.However a short trial of pressure support [**3-28**] with increasedrespiration decreased tidal volume subsequent arterialblood gas of 7.31/84/54 and the patient had to be put backon pressure support of 15 with 5 of PEEP. She spiked to 101and was cultured grew 4Admission Date: [**2180-5-24**] Discharge Date: [**2180-6-2**]Date of Birth: [**2112-4-25**] Sex: FService: FENARD INTENSIVE CARE UNITCHIEF COMPLAINT: Hypoxia.HISTORY OF PRESENT ILLNESS: This is a 68-year-old woman witha history of
chronic obstructive pulmonary disease
DISEASE
historyof
right upper lobe pneumonia
DISEASE
status post prolongedintubation with trache and PEG placements from [**2177-11-24**] to [**2178-12-25**] full exercise tolerance atbaseline
chronic productive cough
DISEASE
with thick-clear sputumbut otherwise not on home O2 or po prednisone who has beenin her usual state of health until about a week prior toadmission when she started to experience increased
fatigue
DISEASE
and
shortness of breath and productive cough
DISEASE
. But otherwiseno
fevers chills
DISEASE
no overt upper
respiratory infection
DISEASE
urinary tract infection
DISEASE
or abdominal symptoms.Two days prior to admission her family noticed a dramaticworsening of
shortness of breath
DISEASE
and increased sputumproduction but otherwise no change in the color or blood inthe sputum. She also had significant worsening of appetite
for two days. She fell at home the day prior to admissiondue to extreme weakness. She was on the floor for about 15minutes but no
loss of consciousness
DISEASE
. She was brought intothe Emergency Room by her family.Her head CT scan was negative for
hemorrhage
DISEASE
. Her
shortness
DISEASE
of breath was much better with nebulizers and IV steroids.However the next day while she was still in the EmergencyRoom she was noticed to have increased
lethargy
DISEASE
and waselectively intubated for an arterial blood gas of pH 7.24pCO2 84 and pO2 of 73. She became significantly
hypotensive
DISEASE
after intubation and required 10 liter normal salineresuscitation. She was started on Neo-Synephrine for bloodpressure support. She was given a dose of levofloxacin andVancomycin for empiric coverage of possible
sepsis
DISEASE
. Herchest x-ray and chest CT scan in the Emergency Departmentsuggested right upper lobe
pneumonia
DISEASE
or other processes.PAST MEDICAL HISTORY:1.
Chronic obstructive pulmonary disease
DISEASE
.2. Severe
emphysema
DISEASE
and
bronchitis
DISEASE
. Pulmonary function testsin [**2178-6-24**] showed a FVC of 1.85 liters FEV1 0.73liters and a FEV1/FVC ratio 39%.3.
Hypertension
DISEASE
.4. Vitamin B12 deficiency.5. Alcohol and benzodiazepine dependency.6. History of
tuberculosis
DISEASE
exposure versus
infection
DISEASE
.7.
Osteoporosis
DISEASE
.8. Status post right upper lobe
pneumonia
DISEASE
in [**2178-10-24**]to [**2178-12-25**] with prolonged intubation with trache andPEG placement.ALLERGIES:1. Bactrim with
nausea
DISEASE
.2. Orajel with benzocaine with
dermatitis
DISEASE
.MEDICATIONS ON ADMISSION:1. Combivent two puffs [**Hospital1 **].2. Serevent two puffs [**Hospital1 **].3. Vitamin B12 250 mcg po q day.4. Flovent two puffs [**Hospital1 **].5. Klonopin 1 mg po bid.6. Atrovent.7. Remeron 30 mg q hs.8. Diltiazem 120 mg po bid.9. Multivitamins one tablet po q day.10. Stool softeners.11. Oxycodone 5 mg prn for
pain
DISEASE
.SOCIAL HISTORY: Two packs per day until last year after the
pneumonia
DISEASE
. Still smokes now and then. Regular alcohol use.Lives with her son and grandson.EXAM ON ADMISSION: Temperature 97.0 heart rate 74 bloodpressure 85/35 respiratory rate 16 O2 saturation 100% onFIO2 100% with vent setting of tidal volume 350 rate of 16PEEP of 5 FIO2 1.0. General: She is intubated but easilyarousable thin chronically sick appearing but otherwise inno acute distress. Head and neck examination is anicteric.Oropharynx is clear. Cardiovascular: Regular rate andrhythm. Lungs: Equal breath sounds bilaterallysignificantly prolonged expiratory phases. Abdomen is softnormal bowel sounds. Extremities no
edema
DISEASE
. Neurologic:Moves all extremities. Lines with Foley and ET tube.LABORATORIES UPON ADMISSION: Arterial blood gas 7.24 84 73preintubation. After intubation 7.07 25 459.Complete blood count: White count of 34.3 hematocrit of43.5 platelets 474. PT of 16.0 PTT 53.4 INR of 1.7.Sodium 135 potassium 4.6 chloride 96 bicarb 31 BUN 9creatinine 0.5 glucose of 133. Urinalysis is negative.Chest x-ray showed increased capacity and pleural thickeningat the right upper lobe concerning for
infection
DISEASE
TB versus
aspergillosis
DISEASE
versus
actinomycosis
DISEASE
versus mucomycosis andalso need to rule out neoplasts.Chest CT scan: Diffuse emphysematous changes with
bullae
DISEASE
right apical thick walled cavity suggesting semi-invasive
aspergillus
DISEASE
versus TB versus
actinomycosis
DISEASE
versusmucomycosis versus neoplasts
multilobular pneumonia
DISEASE
versusaspiration multiple liver lesions.Head CT scan: No evidence of
intracranial hemorrhage
DISEASE
.Sputum Gram stain showed [**11-25**]Admission Date: [**2110-8-26**] Discharge Date: [**2110-8-30**]Date of Birth: [**2053-7-14**] Sex: FService: VASCULARHISTORY OF PRESENT ILLNESS: The patient is a 57 year oldfemale with multiple medical problems who presented with
gangrene
DISEASE
of the right lower extremity required admission for
pain
DISEASE
control intravenous antibiotics and ultimately forright below the knee amputation.PAST MEDICAL HISTORY:1. Coronary
artery disease
DISEASE
status post coronary arterybypass graft complicated by sternal wound
infection
DISEASE
.2. History of Methicillin resistant Staphylococcus aureus
bacteremia
DISEASE
in [**2109-8-3**].3. Diet controlled
diabetes mellitus
DISEASE
.4. Hypertension.5. Hypercholesterolemia.6. Significant tobacco use.7. History of wound abscess in the right lower extremitywhich grew out Methicillin resistant Staphylococcus aureus.8. Status post
AV fistula
DISEASE
in [**2105**].9. Status post coronary artery bypass graft times three thatwas complicated by the sternal wound
infection
DISEASE
[**8-3**] by Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**].10. Status post right femoral to below knee popliteal bypasswith PTFE done in [**3-4**] followed by a right first toeamputation completed in [**3-4**].11. History of cesarean section.12. Questionable history of Penicillin allergy but she doesstate otherwise that she has no known drug allergies.MEDICATIONS ON ADMISSION:1. Nephrocaps one tablet p.o. once daily.2. Norvasc 5 mg twice a day.3. Gabapentin 300 mg q Monday Wednesday and Friday afterhemodialysis.4. Tramadol 50 mg p.o. twice a day p.r.n.5. Trazodone 100 mg q.h.s.6. Medroxyprogesterone 2.5 mg once daily.7. Albuterol MDI.8. Pantoprazole 40 mg p.o. once daily.9. Calcitriol 0.25 mcg once daily.10. Aspirin 81 mg p.o. once daily.11. Epogen 20000 units q Monday Wednesday and Friday withhemodialysis as well as using MSIR 50 mg q12hours.The patient was admitted with increasing right lowerextremity
pain
DISEASE
and low grade temperature. Her admissionwhite count was noted to be 10.4 with a left shifthematocrit 40.0 with a platelet count of 244000.Prothrombin time was 13.7 and INR was 1.3 with a partialthromboplastin time of 28.0. She was on dialysis with ablood urea nitrogen and creatinine of 74 and 6.9respectively. She had an admission potassium of 7.6 whichwas repeated in the Emergency Department and shown to be 8.0.
Hyperkalemia
DISEASE
was emergently treated with calcium chloridebicarbonate dextrose insulin Lasix as she does make someurine as well as emergent hemodialysis and Kayexalate.Upon the day of admission she went to dialysis and receivedher hemodialysis. Her potassium postdialysis was 4.1. Shewas otherwise feeling OK except complaining of persistentright lower extremity
pain
DISEASE
.PHYSICAL EXAMINATION: Her admission examination was notablefor a temperature of 100.1 pulse 90 blood pressure 158/60respiratory rate 18 oxygen saturation 94% in room air. Shewas a
cachectic
DISEASE
female who appeared older than her statedage. The pupils are equal round and reactive to light andaccommodation.
Extraocular movements
DISEASE
are intact. The sclerawere anicteric. She had no
jugular venous distention
DISEASE
and nocarotid bruit. The heart was regular with no gallop. Thelungs were clear but decreased throughout. The abdomen wassoft nontender scaphoid no
hepatosplenomegaly
DISEASE
nopulsatile masses and no bruit. She had palpable femoralpulses bilaterally. Popliteal pulses were not palpable.Distal pulses in the right lower extremity were absent. Shehad some
dry
DISEASE
and wet
gangrene
DISEASE
involving the right forefootwith a failed right first toe amputation site that clearlyhad some purulent exudate.She was admitted for intravenous antibiotics and started onVancomycin Levofloxacin and Flagyl for her hemodialysis.Over the next couple days she was resuscitated adequatelyand ultimately on [**2110-8-26**] she went to the operating roomand received a right below the knee amputation.Postoperatively she did well. She was ruled out by enzymesand kept on telemetry times 24 hours and was uneventful. Herpostoperative white blood cell count was 9.6 and hematocritwas 41.8. Platelet count was 157000. Blood urea nitrogenand creatinine were 58 and 6.3 with a potassium of 5.3. Herphosphate was noted to be elevated at 11.8. Therefore inhospital medications she had her Calcitriol stopped and shewas started on Amphojel and PhosLo. The Amphojel wascontinued for a total of three days of therapy starting on[**2110-8-28**] and to end on [**2110-8-31**]. Over the next couple daysher
pain
DISEASE
was appropriately controlled with Dilaudid PCAalthough the patient demanded that the
Dilaudid
DISEASE
did not workfor her. Therefore she was requesting Morphine. This wasgiven concomitantly and resulted in some mental statuschanges and
confusion
DISEASE
which quickly resolved upon removal ofher narcotic. She had a foot culture from [**2110-8-25**] thatgrew out Methicillin resistant Staphylococcus aureus. Bloodcultures from [**2110-8-24**] were negative. By postoperative daynumber four she continued on triple antibiotics. Hertemperature maximum was 100.1 but a current of 97.4 pulse82 blood pressure 130/70 respiratory rate 18 96% oxygensaturation in room air. Her fingerstick was mildly elevatedbut she was noncompliant and was not taking a
diabetic
DISEASE
orrenal diet. She was taking adequate p.o. Her white bloodcell count at discharge was 9.4. Her blood urea nitrogen andcreatinine were 52 and 6.3 with a potassium of 4.8 andbicarbonate of 21.At this time her stump which had been resected back to thelevel of the proximal one third of the right lower extremitywas clean
dry
DISEASE
and intact with staples in place no
erythema
DISEASE
no exudate no evidence of
hematoma
DISEASE
and the flaps were warm.She was deemed stable and appropriate for discharge by
Dr.[**Name
DISEASE
(NI) 4436**] service.MEDICATIONS ON DISCHARGE:1. Nephrocaps one tablet p.o. once daily.2. Vancomycin to be dosed at time of dialysis times twoweeks dose for trough values less than 15.0.3. Norvasc 5 mg p.o. twice a day.4. Gabapentin 300 mg q Monday Wednesday and Friday afterhemodialysis.5. Tramadol 50 mg p.o. twice a day p.r.n.6. Trazodone 100 mg p.o. q.h.s.7. Medroxyprogesterone 2.5 mg p.o. once daily.8. Albuterol MDI q4hours p.r.n.9. Pantoprazole 40 mg p.o. once daily.10. Calcitriol 0.25 mcg p.o. once daily to be on hold untilfollowed up by her nephrologist.11. Aspirin 81 mg p.o. once daily.12. Folic Acid 1 mg p.o. once daily.13. Epogen 20000 units q Monday Wednesday and Friday withhemodialysis.14. MSIR 50 mg p.o. q12hours.15. Dilaudid 2 to 4 mg p.o. q3-4hours p.r.n. breakthrough
pain
DISEASE
.16. Colace and Pericolace for stool softening agents.FOLLOW-UP: The patient should follow-up with Dr. [**Last Name (STitle) 1391**] inapproximately two to three weeks for skin clip removal. Shewill have right lower extremity remain in knee immobilizerwith a dry dressing and ace wrap to above knee region to helpimmobilize and straighten her leg. She should take part inaggressive physical therapy and learn how to do transfers andso forth. Ultimately she will require outpatient sitting forprosthesis however the stump cannot be used untildesignated by Dr. [**Last Name (STitle) 1391**]. Typically this occurs within sixto eight weeks postoperatively. The patient is deemedappropriate and stable for discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 4417**]Dictated By:[**Last Name (NamePattern4) 4437**]MEDQUIST36D: [**2110-8-30**] 10:13T: [**2110-8-30**] 10:32JOB#: [**Job Number 4438**]cc:[**Last Name (NamePattern1) 4439**]Admission Date: [**2152-9-23**] Discharge Date: [**2152-10-5**]Date of Birth: [**2075-7-16**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2186**]Chief Complaint:
Respiratory distress/hypoxia
DISEASE
Major Surgical or Invasive Procedure:elective intubation [**2152-9-26**]History of Present Illness:77 YO old male with PMH significant for DM HTN high chol CADs/p stents [**2150**]
CHF Afib
DISEASE
s/p PPM [**2150**] CKD who presents to EDbecause of
weakness
DISEASE
and collapse at home. Patient was found onadmission to be
febrile tachypneic
DISEASE
with RUL pneumonia on chestfilm. Patient complained of chronic
cough
DISEASE
with increasing sputumproduction. He denies
fevers chills shortness
DISEASE
of breath
chest pain
DISEASE
. He denies any
loss of consciousness or head trauma
DISEASE
with falls. Denies bowel or
bladder incontinence
DISEASE
or changes infunction. Denies any
weight loss
DISEASE
or changes in eating habits.No abd pain/n/v/d. No
choking
DISEASE
on food reported.Patient was admitted and started on ceftriaxone and azithromycinfor CAP which was then changed to Levoflox and Flagyl as CXRshowed Admission Date: [**2180-2-3**] Discharge Date: [**2180-2-13**]Date of Birth: [**2101-3-2**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:LipitorAttending:[**First Name3 (LF) 1267**]Chief Complaint:
Angina
DISEASE
Major Surgical or Invasive Procedure:Cabg x4 [**2180-2-7**] (LIMA to prox. LAD SVG to distal LAD SVG toramus SVG to OM)History of Present Illness:78 yo male with history of
internmittent angina
DISEASE
for the pastyear relieved by rest. Failed a recent ETT and referred forcath which revealed LM 50-60% 75% LAD CX 95% OM 3 70% RCA30% PDA 75%.
Referred
DISEASE
for CABG.Past Medical History:MICAD s/p angioplasty [**2165**]
HTN
DISEASE
elev. chol.
PSH
DISEASE
: rem. renal calc.rem. cervical disc [**2154**]Social History:Retired: lives alone50 year history of smoking cigarsOccasional ETOHFamily History:Non-contributoryPhysical Exam:VS: Wgt: 76.8 kg preop 72.4 HR: 50's SB BP: 104-110/50-60HEENT unremarkableNeck supple full ROM no
carotid bruits
DISEASE
appreciatedResp: decreased breath sounds bilaterally with crackles 1/4 upon LeftCard: RRR no murmurGI: bowel sounds positive abdomen soft non-tender/non-distenedExtrem: warm well-perfused no
edema
DISEASE
Neuro grossly intactWound: sternal cleandry intact with staples no
erythema
DISEASE
Pulses: 2Admission Date: [**2138-11-15**] Discharge Date: [**2138-11-19**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4052**]Chief Complaint:
Fatigue
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:The patient is a [**Age over 90 **] year old male with a recent diagnosis of
prostate cancer
DISEASE
(he is follwed by Dr. [**First Name4 (NamePattern1) 1313**] [**Last Name (NamePattern1) **] from urology)who presents with 9-10 days of coughing and generalizedweakness. Patient notes light
headedness
DISEASE
-room spining and
orthostatic symptoms
DISEASE
over past several days secondary todecreased po intake. He denies
abdominal pain nausea vomiting
DISEASE
or
diarrhea
DISEASE
. Pt had some mechanical falls recently secondary toinstability probably secondary to
dehydration
DISEASE
. Three weeks agothe patient fell on his right ribs. No obvious
head trauma
DISEASE
. No
fevers chills
DISEASE
or
rigors
DISEASE
at home at home. Patient has lost 15pounds in the last six months. No BRBPR no
melena
DISEASE
.*In ED the patient received ceftriaxone and azitrhomycin alongwith 1 L D5NS x 1 L.*While in MICU patient was aggressively hydrated and started onpressors while being maintained on abx. Patient spontaneouslyconverted to sinus rhythym. He states that his shortness ofbreath has improved. Denies cp abd
pain
DISEASE
dyuria. Is having nl
bowel movements
DISEASE
.Past Medical History:
Prostate cancer
DISEASE
- per pt and daughter no [**Name2 (NI) **] diagnosed by serumbut pt cannot recall numbers Admission Date: [**2174-1-4**] Discharge Date: [**2174-2-2**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2641**]Chief Complaint:hip
fracture
DISEASE
and subsegmental PEMajor Surgical or Invasive Procedure:L HIP ORIFHistory of Present Illness:[**Age over 90 **] year old female with h/o
hypothyroidism anemia
DISEASE
osteoporosis
DISEASE
multiple falls including [**2-20**] and [**3-23**] [**5-23**] whopresents [**1-4**] s/p fall on left hip. Per ambulance report pt wasbehind her apartment door with walker when her physicaltherapist opened the door which hit her causing her to fall.She landed on left hip. She denies LOC
dizziness palpitations
DISEASE
and
confusion
DISEASE
. X-ray confirmed L hip
fracture
DISEASE
..Pt taken to OR [**1-6**] for L ORIF. Intraoperatively she dropped herO2 sats from 100 to 90 and was noted to have an elevated A-agradient. Hip procedure went well without complications.Post-operatively the pt left ventilated on SIMV and orthorequested transfer to MICU for further evaluation and treatment.Past Medical History:Frequent falls [**4-21**] [**11-21**]GERD
Hypothyroidism
DISEASE
Hearing loss
DISEASE
on LeftB12-deficiency Iron deficiency
Anemia
DISEASE
osteoporosis
DISEASE
T3
compression fracture
DISEASE
UTI
DISEASE
Anxiety
DISEASE
ECHO [**11-21**] EFAdmission Date: [**2129-7-7**] Discharge Date: [**2129-7-12**]Date of Birth: [**2086-10-2**] Sex: MService: MEDICINE
Allergies
DISEASE
:Ibuprofen / Ace Inhibitors / Bupropion / Zoloft / AspirinAttending:[**First Name3 (LF) 2195**]Chief Complaint:
GI bleed
DISEASE
Major Surgical or Invasive Procedure:SigmoidoscopyHistory of Present Illness:Patient is a 42yo male with history of CAD s/p stents x 3admitted with
acute GI bleed
DISEASE
..Patient reports being in his normal state of health until thisevening when he developed sudden onset of BRBPR. It occurredaround 9pm. He was taken to the ED by his parents where hecontinued to have lower
GI bleed
DISEASE
. He has never had a
GI bleed
DISEASE
before. Pt denied abd
pain
DISEASE
and n/v no
hematemesis
DISEASE
coffee-ground
emesis
DISEASE
or
melena
DISEASE
. Patient states he has on and offsuprapubic
pain
DISEASE
for the past year and that he has frequent
constipation
DISEASE
with straining and painn with
bowel movements
DISEASE
.Of note he is on aspirin and plavix for coronary stentplacement..In the ED initial vs were: T- 98.0 HR- 118 BP- 184/157 RR-18 SaO2- 98% on
RA
DISEASE
. Patient was initially given 250cc NS buthad persistent
tachycardia
DISEASE
and developed
lightheadedness
DISEASE
. He wasthen give 3U PRBC and 2L NS with resolution of the
tachycardia
DISEASE
.He never became
hypotensive
DISEASE
or had a
fever
DISEASE
. Abdominal exam wasbenign. Rectal exam showed bright red [**First Name3 (LF) **]. NG lavage wasnegative. EKG was unchanged from prior. Hct on admission to ED-45.8 (with normal coags). Patient lost about 1L of [**First Name3 (LF) **] from GItract..GI was consulted and recommended angiogram with embolization asthey were concerned for
diverticulosis
DISEASE
vs
AVM
DISEASE
. General surgerywas also made aware of the patient and are available if needed.IR-team notified and will be coming in tonight to performembolization if needed..On the floor he remained hemodynamically stable. Vitals ontransfer: BP- 126/87 HR- 88 SaO2- 98% on
RA
DISEASE
RR- 12 andafebrile. Patient lost another
100cc
DISEASE
of [**First Name3 (LF) **] on arrival to thefloor but remained hemodynamically stable. He denied anynausea/vomiting
chest pain shortness of breath dizziness
DISEASE
lightheadedness. He did report some lower
abdominal tenderness
DISEASE
to palpation (LAdmission Date: [**2160-12-15**] Discharge Date: [**2160-12-24**]Service: MEDICINE
Allergies
DISEASE
:Ibuprofen / Percocet / Naprosyn / PercodanAttending:[**First Name3 (LF) 1515**]Chief Complaint:
Dyspnea
DISEASE
Major Surgical or Invasive Procedure:ValvuloplastyHistory of Present Illness:[**Age over 90 **] yo female with 3VD CAD s/p MI in [**2156**] POBA
LCX CHF
DISEASE
with EF25% with worsening
RV function dyslipidemia HTN rheumatic
DISEASE
heart disease AV stenosis
DISEASE
s/p valvuloplasty x2 with recent
CHF
DISEASE
exacerbation c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. Patient had been doing well at rehab.Bumex was restarted [**12-12**]. Last night developed SOB and was sentto [**Hospital **] Hosp ER where they felt she was
hypovolemic
DISEASE
andtreated with 2L IVF and sent her back to [**Location (un) **]. This am thepatient experienced worsening SOB. She was treated withMorphine Bumex 1mg x 2 and [**2-2**] of a 1/150 SL nitro x 2 b/c ptc/o
chest tightness
DISEASE
. After taking nitro the pt's BP dropped to90/s the later returned to baseline 100s. At time of transferher O2 sat was 94% on 2Lnc but will dip down to 88% with talkingor sips of water..On the floor the patient was complaining of
dry mouth
DISEASE
and
thirst
DISEASE
and drinking water. She denied SOB
chest pain
DISEASE
or any otherdiscomfort. She denies
cough fever chills
DISEASE
. However she statedshe had had some
delirium
DISEASE
at the rehab due to double dose ofmorphine but was unclear about the exact events. She is awarethat she is at [**Hospital1 **]..The patient has severe
aortic stenosis
DISEASE
with low output (EF Admission Date: [**2175-1-28**] Discharge Date: [**2175-3-4**]Service: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4111**]Chief Complaint:aspiration
pneumonia
DISEASE
Major Surgical or Invasive Procedure:G-J tube replacementPICC line placementHistory of Present Illness:Patient is a [**Age over 90 **] year old man with a long history of a persistentvegetative state recently admitted to [**Hospital1 112**] with an aspiration
pneumonia
DISEASE
. He required intubation and was maintained on TPN andtube feedings until he was able to be extubated and dischargedto rehab. He returns after only a few days after a presumedepisode of reaspiration again requiring intubation and pressorsupport.Past Medical History:-Alzheimer disease-persistent vegetative state-GERD-h/o aspiration PNA-osteopenia-atrial
fibrillation
DISEASE
-myoclonusSocial History:Has been cared for by his daughter for the past three years.Family History:NoncontributoryPhysical Exam:Gen unresponsive resting comfortablyNeck flexed with no massesCV RRR no m/r/gResp coarse BS bilaterallyAbd mildly distended slightly firm GJ tube in placeExt [**12-19**]Admission Date: [**2188-5-9**] Discharge Date: [**2188-5-14**]Date of Birth: [**2121-7-18**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2074**]Chief Complaint:Direct transfer from [**Hospital3 417**] Hospital for STEMI cath andnow stablized hct and transfered out of CCUMajor Surgical or Invasive Procedure:Cardiac catheterizationBlood transfusionHistory of Present Illness:Mr. [**Known lastname 2391**] is a 66-year-old male with hx HIV on HAART
lymphoma LUL lung adenocarcinoma
DISEASE
s/p resection hx CAD s/p PCIwith DES in [**5-17**] to proximal circumflex artery. In [**11-16**] he hadelective cath showing 90%
restenosis
DISEASE
at proximal edge ofpreviously placed stent treated with overlapping Cyper stent.Mid-RCA was 80% occluded and treated with DES as well. In [**2-18**]pt had a left femoral artery to dorsalis pedis artery bypassgraft with an in situ greater saphenous vein graft. His plavixwas discontinued at that time. He was recently admitted on[**2188-4-30**] w/ STEMI over III F taken to cath where he had a DESplaced in the LCX for the vessel being occluded by a
thrombus
DISEASE
proximally. Of note at cath [**4-30**] he had a totally occludedright external iliac artery. The pt was discharged home [**2188-5-3**].Since that time per the pt he felt at baseline with theexception of
intermittent left leg pain
DISEASE
(s/p vascular surgerybypass) that would occasionally awaken him at night. He statedhe was up this morning at 4am b/c of this left leg
pain
DISEASE
when hedeveloped a Admission Date: [**2175-3-10**] Discharge Date: [**2175-5-10**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 3984**]Chief Complaint:AspirationMajor Surgical or Invasive Procedure:Intubation repostitioning G-Tube change of G-tube to G-J tubeHistory of Present Illness:Mr. [**Known lastname 4476**] is a [**Age over 90 **] year old man with a long history of
end-stage dementia
DISEASE
for at least 10 years with recurrentaspiration
pneumonias
DISEASE
and pressure
ulcers
DISEASE
who presents to the[**Hospital1 18**] ED from [**Hospital **] Rehab with an aspiration. He was recentlydischarged from [**Hospital1 18**] [**3-3**] after he had an aspiration and had aprolonged intubation. He was treated with vanc/zosyn for a twoweek course which was completed [**3-5**]. Today nursing at [**Hospital1 **]noted that his abdomen was somewhat distended. A KUB wasperformed that showed the feeding tube was coiled in his stomachin a different position. Tube feeds were restarted and thefeeding tube was noted to be further displaced with the phlangeout of place. The patient was turned and began
vomiting
DISEASE
and
gagging
DISEASE
and was suctions. His VS when he was evaluated therewere T 98.8 BP 119/76 RR 32 Sat 90% on 60%
FM
DISEASE
..The patient was brought to the [**Hospital1 18**] ED evaluation. In the EDhe was immediately intubated and started onlevaquin/vanc/flagyl for presumed aspiration
pneumonia
DISEASE
. Hetransiently dropped his blood pressure to a systolic of 80'sover 30's and was started on levophed.Past Medical History:End-stage Alzheimers
Atrial fibrillation
DISEASE
Recurrent aspiration
pneumonias
DISEASE
h/o MRSA and VRE colonization
Myoclonus
DISEASE
Social History:Recently discharged from [**Hospital1 18**] to [**Hospital **] rehab.Has been cared for by his daughter for the past three years.Family History:NoncontributoryPhysical Exam:VS: (on arrival to the MICU) T 98.9 HR 100 BP 75/33 RR 21 Sat98%Vent: AC Tv 500 RR 14 PEEP 8 FiO2 60%GEN: unresponsive intubated man on a intubated and sedated on aventilatorHEENT: Dry MM
sclerae anicteric
DISEASE
pinpoint pupils.CV: Distant heart sounds irregularPUL:
Coarse rhonchi
DISEASE
throughoutABD: Distended no rebound or guarding.EXT: 1Admission Date: [**2116-12-14**] Discharge Date: [**2116-12-25**]Date of Birth: [**2037-1-21**] Sex: MService: NEUROSURGERY
Allergies
DISEASE
:CodeineAttending:[**First Name3 (LF) 1271**]Chief Complaint:Weakness for one weekMajor Surgical or Invasive Procedure:RIGHT CRANIOTOMY FOR EVACUATION OF SUBDURAL HEMORRHAGEHistory of Present Illness:79 year old male presents with generalized
weakness
DISEASE
for thelast week. He says that he feels like he has been moving slowand his wife notes that he has needed help getting dressed anditseems like he is dragging his left leg sometimes. He denies anyfalls but does note that he sometimes feels like he loses hisbalance. No other complaints no history of
trauma
DISEASE
no
headaches
DISEASE
.(per admission note)Past Medical History:
chronic UTIs hypercholesterolemia HTN
DISEASE
Social History:lives with wife denies tobacco or EtOH useFamily History:n/cPhysical Exam:PHYSICAL
EXAM
DISEASE
ON ADMISSION:O: T: 97.1 BP: 126/74 HR: 60 R 16 O2Sats 97%
RA
DISEASE
Gen: WD/WN comfortable NAD.HEENT: Pupils: PERRL EOMs intactNeck: Supple.Lungs: CTA bilaterally.Cardiac: RRR. S1/S2.Abd: Soft NT BSAdmission Date: [**2107-5-26**] Discharge Date: [**2107-6-9**]Date of Birth: [**2029-5-6**] Sex: FService: SURGERY
Allergies
DISEASE
:Cortisone / Percocet / Prednisone / Advair DiskusAttending:[**First Name3 (LF) 3376**]Chief Complaint:
Abdominal pain
DISEASE
Major Surgical or Invasive Procedure:[**2107-5-26**]: Exploratory laparotomy with ileocolectomyHistory of Present Illness:78F s/p laparoscopic converted to open right hemicolectomy forStage 1 (T1N0) right
colon cancer
DISEASE
on [**2106-10-29**] now beingtransferred from OSH with diffuse
abdominal pain
DISEASE
and guarding onexam. She started with diffuse
abdominal pain
DISEASE
at 9am yesterdayand went to [**Hospital3 4485**] at 9pm. She had some
nausea
DISEASE
and
bilious emesis
DISEASE
x5 but had been passing flatus and bowelmovements. A non-contrast CT was performed and she was sent hereas her abdominal exam was concerning. In ED with A.fib w/RVR
hypertension
DISEASE
up to 200/100.Past Medical History:CAD s/p PCI (last '[**02**]) pAFib
CHF HTN
DISEASE
hyperchol
interstitial lung disease GIB
DISEASE
GERD CRI (baselineCr1.3-1.8)
NIDDM hypothyroid TIA parkinson's
DISEASE
low
back pain
DISEASE
Past Surgical History:Diverting transverse loop colostomy after
colonic perforation
DISEASE
from colonoscopy colostomy reversal
ventral hernia
DISEASE
repairwith mesh Laparoscopic converted to open right hemicolectomy[**2106-11-15**].Social History:Patient is retired lives at home with husband. Former [**Name2 (NI) 1818**].Denies alcohol or other drugs.Family History:NCPhysical Exam:On admission:Vitals: T 101.1 HR 160 BP 120/90 RR 20 SO2 96%GEN: A&O NADHEENT: No scleral icterus mucus membranes moistCV: RRR No M/G/RPULM: Clear to auscultation b/l No W/R/RABD: Firm nondistended severely tender diffusely mild rebound
tenderness
DISEASE
and voluntary guarding.DRE: normal tone no gross or occult bloodExt: 1Admission Date: [**2110-2-21**] Discharge Date: [**2110-2-24**]Date of Birth: [**2052-12-15**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2485**]Chief Complaint:
Dyspnea
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:57 y/o man with a history of aoritc valve replacement [**2102**] [**2-24**]
congenital bicuspid valve
DISEASE
copd
HTN
DISEASE
prior alcohol abuse whois admitted to the [**Hospital Ward Name **] ICU with
dyspnea
DISEASE
and transient
hypotension
DISEASE
..The patient was recently admitted to [**Hospital1 18**] from [**2110-1-28**] to[**2110-2-2**] for
dyspnea
DISEASE
and was treated for a
COPD
DISEASE
excaerbation withsteroids and azithromycin. An echocardiogram performed duringthe admission was normal without significant impairment inrelaxation. He completed his course but continued to havesymtpoms. In fact VNA contact[**Name (NI) **] his PCP (who had not yet methim) on [**2-13**] with concerns that included continued
dyspnea
DISEASE
areported 20lb
weight gain
DISEASE
and
lower extremity edema
DISEASE
. Thepatient began 20mg lasix at that time..On presentation to his new PCPs office [**2110-2-21**] he had acontinued oxygen requirment of 3L at rest sating 95% and 90%with ambulation. The patient endorsed
dyspnea
DISEASE
walking even 30feet. He was sent to the ED for a rule out of PE. per reportshe was moving air well at that time and did not have
wheezing
DISEASE
.He had just completed his prescribed steroid taper on [**2-19**] whichwas a total of 14 days..On arrival to the ED he was 96.9 124/59 91 24 95%on 3LIn the ED he was given lasix 40mg IV x 1 and a CTA was obtained.The CTA was negatvie for PE. The lasix dropped his bloodpressure transiently to 75/40 which was response to a total of2L normal saline challenge. He was not given steroids ornebulizers. Despite resolution of his
hypotension
DISEASE
he was sentto the [**Hospital Unit Name 153**]..Further review of systemts notable for minimal
cough
DISEASE
no
fever
DISEASE
and no
chest pain
DISEASE
. He does not occasional paroxysmal abdominal
pain
DISEASE
for which a RUQ u/s on [**1-28**] was negative for acutepathology. He notes leg
swelling
DISEASE
for which tight socks havehelped. He also reports difficulty sleeping requiring 3 pillowsat night. He reports that he did not feel completely betterduring his hospitlization at [**Hospital1 18**] notable that he did not tryand walk around much. He thinks that his
shortness of breath
DISEASE
hasbeen much worse since [**2109-12-23**] allthough clearly he musthave marked
dysfunction given disability
DISEASE
[**2-24**]
dyspnea
DISEASE
. Formerpatient of [**Hospital1 2177**] and a comprehensive review of old records is notavailable at this time..Past Medical History:#
COPD
DISEASE
- was seen frequently at [**Hospital6 **]. Hassmoked 3 packs /day x 45 years quit on last admission to [**Hospital1 18**].No PFTs in our system.# Congential Bicuspid Aortic ValveAdmission Date: [**2112-5-6**] Discharge Date: [**2112-5-12**]Date of Birth: [**2052-12-15**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 1253**]Chief Complaint:
Respiratory distress
DISEASE
.Major Surgical or Invasive Procedure:1. Inubation2. Placement of central venous access via the right internaljugularHistory of Present Illness:Mr. [**Known lastname 4509**] is a 59yo M with history of severe
COPD
DISEASE
and pulmonary
hypertension
DISEASE
who was brought in by ambulance for respiratorydistress. Per report when EMS arrived all of his inhalers wereempty..In the ED initial vs were: T 98.8 P 121 BP 100/67 R 17 O2 sat100%. He was immediately intubated for
respiratory distress
DISEASE
ashe wasn't able to speak few words. He was on propofol forsedation. His pressures were in the 90s and dipped to the 80sso R IJ was placed and levophed was started. CXR showed fluffybilateral infiltrates and ABG was significant for
hypcarbia
DISEASE
to106. He received 125mg IV solumedrol albuterol magnesiumlevaquin ceftriaxone and was started on versed/fent drips..In the ICU patient is intubated and sedated.Past Medical History:#
COPD
DISEASE
- was seen frequently at [**Hospital6 **]. Hassmoked 3 packs /day x 45 years quit on last admission to [**Hospital1 18**].No PFTs in our system.# Congential Bicuspid Aortic ValveAdmission Date: [**2194-7-24**] Discharge Date: [**2194-8-3**]Service: [**Hospital1 139**] - Medicine and MICUHISTORY OF PRESENT ILLNESS: This 84-year-old female with ahistory of
diverticula CREST
DISEASE
and
irritable bowel syndrome
DISEASE
presented to the Emergency Room with a chief
complaint
DISEASE
of
epigastric pain lightheadedness nausea
DISEASE
without
emesis
DISEASE
anddark stools. She denied
chest pain shortness of breath
DISEASE
cough fevers chills
DISEASE
and night sweats. In the EmergencyRoom she was found to have a blood pressure of 130/palp witha heart rate of 72. One hour later this was 119/39 with apulse of 100. She had heme positive stool and hematocrit wasfound to be 16.6. The patient therefore had an emergent EGDin the GI unit. No nasogastric lavage was performed.PAST MEDICAL HISTORY: The patient has
Sjogren
DISEASE
's with
sicca
DISEASE
syndrome and presumed
CREST
DISEASE
with a history of
dysphagia
DISEASE
and
dyspepsia
DISEASE
. The patient's primary gastroenterologist is Dr.[**Last Name (STitle) 1940**]. Patient has a history of
hypertension
DISEASE
hypothyroidism irritable bowel syndrome
DISEASE
with chronic
diarrhea Raynaud
DISEASE
's history of
TAH
DISEASE
cholecystectomy andpericholecystectomy
hernia
DISEASE
repair
COPD
DISEASE
and
bronchiectasis
DISEASE
right
bronchial sclerosis
DISEASE
and
Sjogren
DISEASE
's history of bladderstretchings negative MRCP [**6-18**] except for some
liver cysts
DISEASE
diverticula
DISEASE
on colonoscopy [**7-/2193**] with possibility of
Crohn
DISEASE
'snoted.SOCIAL HISTORY: The patient smoked some tobacco in the pastbut it was a small amount. She drinks no alcohol.FAMILY HISTORY:
Crohn's disease
DISEASE
.ALLERGIES: Penicillin Bactrim and Sulfa.MEDICATIONS: Norvasc 10 mg q d Atenolol 50 mg q d Levoxyl1.25 mg q d Dyazide 37.5/25 q d Serax prn occasionalNSAIDs Premarin .625 mg q d and Aspirin.PHYSICAL EXAMINATION: Temperature 97 blood pressure 95/69respiratory rate 14 satting 100% on two liters. The patientwas alert and oriented times three she was fully conversantand awake interactive and appropriate. She was in no acutedistress. Conjunctiva were pale. She had dry mucusmembranes. She was normocephalic atraumatic extraocularmovements intact pupils were equal round and reactive tolight. There was no JVD. Neck was supple. TMs were normal.There was no
lymphadenopathy
DISEASE
of the neck faint bibasilarcrackles were heard on lung exam. The patient wastachycardic with a normal S1 and S2 with 2/6 systolicejection murmur radiating to the axilla. Abdomen was softand non distended with normal bowel sounds was mildly tenderto deep palpation. Extremities without
clubbing cyanosis
DISEASE
or
edema
DISEASE
. Fingers were cool as were the toes but she had 1Admission Date: [**2195-6-17**] Discharge Date: [**2195-7-7**]Service: [**Hospital1 **]HISTORY OF PRESENT ILLNESS: This is an 84 year-old femalewith a history of
CREST diverticular disease irritable
DISEASE
bowel syndrome
DISEASE
and prior upper GI bleed in [**7-19**] secondary to
AVM
DISEASE
and
gastritis
DISEASE
. Her previous
UGIB
DISEASE
requiredhospitalization which was notable for a hematocrit of 16 onduring stay 2 units of fresh frozen plateletsesophagogastroduodenoscopy showing
gastritis
DISEASE
and normalduodenum cauterization of a
gastric AVM
DISEASE
and angiographyfollowed by embolization of left gastric artery.She presented to the Emergency Room at this time with a chief
complaint
DISEASE
of two days of dark stools left lower abdominal
breath lightheadedness fevers
DISEASE
or
chills
DISEASE
and night sweats.No bright red blood per rectum no
hematemesis
DISEASE
. In theEmergency Room she was found to be in no acute distress andwith a temperature of 99.5 blood pressure 143/53 pulse 86respirations 16 98% on room air. Nasogastric suctionrevealed 200 cc of coffee grounds and lavage with 250 cc H20showed coffee grounds and a bright red tinge but lavage wasstopped because of patient discomfort. Central line infemoral vein was placed and she was given one liter of normalsaline.PAST MEDICAL HISTORY: 1. Sjogren's with
Sicca syndrome
DISEASE
CREST
DISEASE
with a history of
dysphagia
DISEASE
and
dyspepsia
DISEASE
(followed bygastroenterologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**]). 2. Hypertension.3. Hypothyroidism. 4. Irritable bowel syndrome withchronic
diarrhea constipation
DISEASE
and
abdominal pain
DISEASE
. 5.Diverticula seen on colonoscopy [**7-/2193**]. 6. Chronic
obstructive pulmonary disease
DISEASE
with
bronchiectasis
DISEASE
right
bronchial sclerosis
DISEASE
. 7. History of bladder stretching.PAST SURGICAL HISTORY: 1. Cholecystectomy. 2.Pericholecystectomy
hernia
DISEASE
repair. 3. Hysterectomy.SOCIAL HISTORY: Three pack years of smoking quit twentyyears ago. Drinks no alcohol.FAMILY HISTORY: Son has
Crohn's disease
DISEASE
times forty twoyears.ALLERGIES: Penicillin and sulfa.MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg q.d. 2.Aldactone 25 mg t.i.d. 3. Lasix 20 mg q.d. 4. Synthroid175 micrograms q.d. 5. Prevacid 30 mg q.d. 6. Evoxac 30mg t.i.d. 7. Serax 50 mg b.i.d. 8. Multivitamin once aday.PHYSICAL EXAMINATION: General thin elderly woman in noacute distress. Vital signs temperature 99.5. Bloodpressure 120/60. Pulse 86. Respiratory rate 18. Skinnormal capillary refill plus
telangiectasias
DISEASE
on the back.
HEENT right ptosis
DISEASE
. No
scleral icterus
DISEASE
. Pupils are equalround and reactive to light.
Extraocular movements
DISEASE
intact.Mucous membranes are dry. No lower dentition. Neck supple.No
lymphadenopathy
DISEASE
. Jugular veins flat. Chest clear toauscultation bilaterally. Cardiovascular regular rate andrhythm. S1 and S2. 3 out of 6 systolic murmur loudest atright upper sternal border. No gallops or rubs. Abdomenflat. Scar along right abdomen. Positive bowel soundsnondistended. No
tenderness
DISEASE
to palpation. No
hepatosplenomegaly
DISEASE
. Extremities no
clubbing cyanosis
DISEASE
or
edema
DISEASE
. Fingers and toes cool to touch. 2Admission Date: [**2195-6-17**] Discharge Date: [**2195-7-7**]Service: [**Hospital1 **]HISTORY OF PRESENT ILLNESS: This is an 84 year-old femalewith a history of
CREST diverticular disease irritable
DISEASE
bowel syndrome
DISEASE
and prior upper GI bleed in [**7-19**] secondary to
AVM
DISEASE
and
gastritis
DISEASE
. Her previous
UGIB
DISEASE
requiredhospitalization which was notable for a hematocrit of 16 onadmission 11 units of packed red blood cells transfusionduring stay 2 units of fresh frozen plateletsesophagogastroduodenoscopy showing
gastritis
DISEASE
and normalduodenum cauterization of a
gastric AVM
DISEASE
and angiographyfollowed by embolization of left gastric artery.She presented to the Emergency Room at this time with a chief
complaint
DISEASE
of two days of dark stools left lower abdominal
pain
DISEASE
and
weakness
DISEASE
. She denied
chest pain shortness
DISEASE
of
breath lightheadedness fevers
DISEASE
or
chills
DISEASE
and night sweats.No bright red blood per rectum no
hematemesis
DISEASE
. In theEmergency Room she was found to be in no acute distress andwith a temperature of 99.5 blood pressure 143/53 pulse 86respirations 16 98% on room air. Nasogastric suctionrevealed 200 cc of coffee grounds and lavage with 250 cc H20showed coffee grounds and a bright red tinge but lavage wasstopped because of patient discomfort. Central line infemoral vein was placed and she was given one liter of normalsaline.PAST MEDICAL HISTORY: 1. Sjogren's with
Sicca syndrome
DISEASE
CREST
DISEASE
with a history of
dysphagia
DISEASE
and
dyspepsia
DISEASE
(followed bygastroenterologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**]). 2. Hypertension.3. Hypothyroidism. 4. Irritable bowel syndrome withchronic
diarrhea constipation
DISEASE
and
abdominal pain
DISEASE
. 5.Diverticula seen on colonoscopy [**7-/2193**]. 6. Chronic
obstructive pulmonary disease
DISEASE
with
bronchiectasis
DISEASE
right
bronchial sclerosis
DISEASE
. 7. History of bladder stretching.PAST SURGICAL HISTORY: 1. Cholecystectomy. 2.Pericholecystectomy
hernia
DISEASE
repair. 3. Hysterectomy.SOCIAL HISTORY: Three pack years of smoking quit twentyyears ago. Drinks no alcohol.FAMILY HISTORY: Son has
Crohn's disease
DISEASE
times forty twoyears.ALLERGIES: Penicillin and sulfa.MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg q.d. 2.Aldactone 25 mg t.i.d. 3. Lasix 20 mg q.d. 4. Synthroid175 micrograms q.d. 5. Prevacid 30 mg q.d. 6. Evoxac 30mg t.i.d. 7. Serax 50 mg b.i.d. 8. Multivitamin once aday.PHYSICAL EXAMINATION: General thin elderly woman in noacute distress. Vital signs temperature 99.5. Bloodpressure 120/60. Pulse 86. Respiratory rate 18. Skinnormal capillary refill plus
telangiectasias
DISEASE
on the back.
HEENT right ptosis
DISEASE
. No
scleral icterus
DISEASE
. Pupils are equalround and reactive to light.
Extraocular movements
DISEASE
intact.Mucous membranes are dry. No lower dentition. Neck supple.No
lymphadenopathy
DISEASE
. Jugular veins flat. Chest clear toauscultation bilaterally. Cardiovascular regular rate andrhythm. S1 and S2. 3 out of 6 systolic murmur loudest atright upper sternal border. No gallops or rubs. Abdomenflat. Scar along right abdomen. Positive bowel soundsnondistended. No
tenderness
DISEASE
to palpation. No
hepatosplenomegaly
DISEASE
. Extremities no
clubbing cyanosis
DISEASE
or
edema
DISEASE
. Fingers and toes cool to touch. 2Admission Date: [**2196-5-13**] Discharge Date: [**2196-5-16**]Service:CHIEF COMPLAINT: GI bleed transfer from [**Hospital3 4527**].HISTORY OF PRESENT ILLNESS: The patient is an 85-year-oldwoman with a history of
Sjogren syndrome
DISEASE
with
sicca syndrome
DISEASE
and also
CREST
DISEASE
with predominant
Raynaud
DISEASE
's history of GI
bleed
DISEASE
in the past thought secondary to
gastritis
DISEASE
and
arteriovenous malformations
DISEASE
status post left gastric andleft gastroduodenal artery embolizations in [**7-18**] and [**6-18**]respectively. She presented to [**Hospital3 4527**] in mid-[**2196-4-17**] with bright red blood per rectum and an hematocrit dropfrom 34 to 28. Her work-up at that time consisted of anabdominal CT that revealed a
pancolitis
DISEASE
increased
splenomegaly
DISEASE
and new
ascites
DISEASE
. She was transfused two unitsand discharged to rehabilitation on [**2196-5-7**] and then two tothree days prior to admission the patient noted dark stoolsand on the morning prior to admission the patient had
nausea
DISEASE
decreased appetite and an episode of
vomiting
DISEASE
bright redblood. She subsequently went to [**Hospital3 4527**] on [**2196-5-12**]in the morning. In the emergency room there her systolic wasin the 90s hematocrit was 18 down from 28 on discharge.Her INR was 1.7. She had a left IJ triple-lumen catheterplaced a right EJ peripheral line and she subsequentlyunderwent EGD which revealed grade 0-1 esophageal varices
portal gastropathy gastric varices
DISEASE
but no
active bleed
DISEASE
although there were multiple blood clots in the stomach. Shewas treated with IV Protonix and was started an octreotidedrip. She was transfused several units which improved herhematocrit from 18 to 28 and then on the morning of the 27tharound 1 AM she had a repeat episode of
hematemesis
DISEASE
andnasogastric lavage did not clear after two liters of saline.An emergency EGD was performed that revealed a large
varix
DISEASE
atthe gastroesophageal junction and there was blood in thefundus. Sclerotherapy was attempted which resulted in aninitial blood spurt however the
bleeding
DISEASE
subsequentlystabilized and overall during the resuscitative efforts shewas given six units of red cells and four units of freshfrozen plasma and she was transferred to [**Hospital1 346**] for evaluation of emerging TIPS.Here in the intensive care unit the patient was comfortablewith no
nausea
DISEASE
or
vomiting
DISEASE
no further
hematemesis
DISEASE
. Shedenied any
abdominal pain
DISEASE
.PAST MEDICAL HISTORY: 1.
Sjogren
DISEASE
's with
sicca syndrome
DISEASE
. 2.
CREST
DISEASE
with predominant
Raynaud
DISEASE
's. 3. History of
GI bleed
DISEASE
status post left gastric artery embolization in [**7-18**] andleft gastroduodenal artery embolization in [**6-18**]. 4. Historyof
pancolitis
DISEASE
. 5. Recent episode of
bleeding
DISEASE
points. 6.
Irritable bowel syndrome
DISEASE
. 7.
Hypertension
DISEASE
. 8.
Hashimoto
DISEASE
's
hypothyroidism
DISEASE
with positive antibody. 9. Diverticulosis.10. History of left femoral
DVT
DISEASE
in [**6-18**]. 11. History of
chronic obstructive pulmonary disease/bronchitis
DISEASE
.MEDICATIONS: 1. Octreotide drip at 50 mcg per minute. 2.Protonix 40 IV b.i.d. 3. Ativan p.r.n. 4. Atroventalbuterol nebulizers. 5. Vitamin K subcutaneous x 3.ALLERGIES: The patient is
allergic
DISEASE
to sulfa and penicillin.SOCIAL HISTORY: The patient lives in [**Location (un) 4528**] skillednursing facility. Her son lives locally daughter is on thewest coast. Minimal alcohol history and remote tobacco. Thepatient has a son with [**Name (NI) 4522**] disease.PHYSICAL EXAMINATION: On arrival her temperature was 98blood pressure 160/80 heart rate 80s respiratory rate 16saturating 95% on two liters. General: She was awell-appearing elderly frail woman. HEENT: She hadcrusted blood in her oropharynx. Pupils equal round andreactive to light. Sclerae anicteric. Neck: Supple withno
lymphadenopathy
DISEASE
. Chest: Examination revealed decreasedbreath sounds at the left base and
bronchial breath sounds
DISEASE
atthe right base. Cardiac: There was a [**12-24**]
crescendo/decrescendo systolic murmur
DISEASE
at the right uppersternal border without radiation. Abdomen: Benign positivebowel sounds nontender. There was no fluid wave. No liveredge was appreciated. Extremities: There was no peripheral
edema
DISEASE
. Skin: There was no
jaundice
DISEASE
notable. Neurologic:The patient was alert and oriented x 3 otherwise nonfocal.LABORATORY DATA: On the morning of admission white count was10.8 hematocrit 31.9 which had been up from 22 earlier inthe morning platelet count 68 which was around herbaseline SMA-7 was unremarkable. BUN and creatinine werenormal. INR was 1.3. PT 14.1 PTT 32.8 fibrinogen was 161albumin 3.2. ALT AST and alkaline phosphatase were withinnormal limits. Total bilirubin was 2.1. Urinalysis on themorning of arrival had been negative.EKG showed
sinus tachycardia
DISEASE
at [**Street Address(2) 4529**] depressions in 23 aVF V4 to V6 but no acute change compared to old.HOSPITAL COURSE: 1. Upper GI bleed/variceal bleed: Patientwas thought to have
cirrhosis
DISEASE
of unclear etiology with new
ascites
DISEASE
and new
splenomegaly
DISEASE
on recent abdominal CT and onendoscopy at the outside hospital portal
gastropathy
DISEASE
and
esophageal varices
DISEASE
were found. The patient was initiallytransferred to [**Hospital1 69**] forevaluation for emerging TIPS. The patient had a type andcross with four units of red cells and fresh frozen plasma onhold. She had a central line in her left neck as well as aright EJ. She was continued on octreotide drip at 50 mcg perhour. She was continued on Protonix 40 IV b.i.d. Her
coagulopathy
DISEASE
her hematocrit and platelet count werecorrected with products as needed. The patient was evaluatedby the liver team who felt that given her comfortable statusand high risk of precipitating
encephalopathy
DISEASE
TIPS would notbe the best strategyAdmission Date: [**2193-8-5**] Discharge Date: [**2193-8-7**]Date of Birth: [**2118-7-9**] Sex: FService: MEDICINE
Allergies
DISEASE
:Sulfa (Sulfonamide Antibiotics)Attending:[**First Name3 (LF) 1711**]Chief Complaint:s/p
VF arrest
DISEASE
Major Surgical or Invasive Procedure:A-line placementHistory of Present Illness:75 yo female with
DM
DISEASE
presenting with
VF arrest
DISEASE
. Per patient'shusband patient was at home with her husband this morning.Husband was outside walking the dog and when he walked in heardhis wife call out for him then heard her collapse. He was ather side immediately could not feel a pulse. He gave herglucagon as she has a history of
hypoglycemia
DISEASE
with no effect.He called 911 within 5-10 minutes of finding her down. 911responded within 2 minutes and defibrillated immediately. Shereceived three rounds of epinephrine intubated and started ondopamine gtt..Initial vital signs in ED were HR 120 BP 75/p. EKG showed afibwith rate [**Street Address(2) 4531**]
depressions
DISEASE
in V1-V5. Initial labs showedno
leukocytosis
DISEASE
normal hematocrit and were significant for a pHof 7.17 lactate of 8.8 bicarb of 16 and glucose of 178.Patient was given a lidocaine bolus and started on a drip. Shewas also given levophed for further pressure support in additionto dopamine drip. She was seen by cardiology and given anamiodarone bolus and drip for rate control. Post
cardiac arrest
DISEASE
hypothermia
DISEASE
protocol was initiated..On arrival to the CCU patient's VS were HR90 in SR withfrequent PVCs BP 111/55 on levophed (dopamine was discontinuedprior to transfer)..According to husband patient had no recent complaints of chest
pain shortness of breath orthopnea
DISEASE
or paroxysmal nocturnal
dyspnea
DISEASE
. She has known cardiac history. She is a type I
diabetic
DISEASE
and has
neuropathy
DISEASE
and
diabetic retinopathy
DISEASE
. She islegally blind.Past Medical History:1. CARDIAC RISK FACTORS: Type I diabetes2. CARDIAC HISTORY:- None.3. OTHER PAST MEDICAL HISTORY:- Type I diabetes- Glaucoma- Diabetic neuropathy- Diabetic retinopathy legally blindSocial History:Lives with husband who was an ophthalmologist. Active incommunity. No children.- Tobacco history: Never- ETOH: Occasional- Illicit drugs: DeniesFamily History:Non contributoryPhysical Exam:Admission Physical Exam:VS: TAdmission Date: [**2194-1-7**] Discharge Date: [**2194-2-2**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:Altered Mental Status and
hypotension
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:[**Age over 90 **]F Russian-speaking h/o refractory nodular sclerosing Hodgkins
Lymphoma
DISEASE
was brought in by EMS and admitted after her homehealth care aide noted she was
hypotensive
DISEASE
to 88/40 andconfused.In the ED T 98.4 (rectal) HR 101 BP 102/53 RR 20 O2Sat 98%on 3L. Incontinant of guaiac-positive stool. Treated with 4 LNS vanco 1g IV ceftazadime 1g IV and flagyl 500mg IV.Received 0.5 mg ativan and 2mg IV morphine for
agitation
DISEASE
.Pt was admitted to [**Hospital Unit Name 153**] where she completed a 10-day course ofceftazadime and vancomycin for
urosepsis
DISEASE
. A 7-day course ofmetronidazole was also completed for empiric treatment of C.Diff given loose stools in the setting of an elevated WBC countalthough all C. Diff assays were negative. Pt was stabilized andwas transferred to the floor for further care. At the time oftransfer active issues were poor nutritional status
thrombocytopenia
DISEASE
and
anemia
DISEASE
.On the floor however pt experienced an episode of new
Afib
DISEASE
with RVR to 160s and
hypotension
DISEASE
to SBP 90-100s as well as
respiratory distress
DISEASE
after she received fluid resuscitation.There was also a concern for
tachy-brady
DISEASE
syndrome because shehad pauses up to 4 sec on telemetryAdmission Date: [**2157-5-16**] Discharge Date: [**2157-5-21**]Date of Birth: [**2088-4-1**] Sex: FService: UROLOGY
Allergies
DISEASE
:Aspirin / Motrin / Trilisate / Naprosyn / Toradol / Vicodin /Percocet / Indocin / Dilaudid / ZomigAttending:[**First Name3 (LF) 4533**]Chief Complaint:
Kidney stone
DISEASE
Major Surgical or Invasive Procedure:Left pyeloscopy with laser lithotripsy and stent exchange[**2157-5-16**] Dr. [**First Name (STitle) **]Flexible sigmoidoscopy [**2157-5-20**] GI service.PICC [**2157-5-21**]History of Present Illness:Ms. [**Known lastname **] is a 69-year-old femalewho presented in [**Month (only) 958**] with an obstructing 5-mm left UPJstone with mild
hydronephrosis
DISEASE
. She was managed at that timewith stent placement and delayed stone management given acute
diverticulitis
DISEASE
at that time. The patient presented on admissionfordefinitive stone management and she elected to undergoureteroscopy with laser lithotripsy and stent change. Ofnote on preoperative testing she had a white count of 19.0.Given concern for
diverticulitis
DISEASE
she was given ceftriaxoneand Flagyl before the time of surgery and was scheduled to beadmitted for observation.Past Medical History:
NIDDM HTN hypercholesterolemia
DISEASE
Incisional ventral hernia
DISEASE
repair [**5-16**]
TAH
DISEASE
'[**30**]R knee arthroscopySocial History:non-contributoryFamily History:non-contributoryPhysical Exam:Discharge Exam:AVSSGen: NADCV: RRRResp: CTA-BAbd: obese s/nt/ndAdmission Date: [**2145-11-14**] Discharge Date: [**2145-11-18**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2297**]Chief Complaint:Found
Down
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:[**Age over 90 **] yo male with
chronic kidney disease
DISEASE
who presents to the EDafter being found down at apt. Pt found by landlord after notbeing seen in 2 days and found in own feces..ED: While in the ED found to have K of 7 creat of 10 trop of3 with nl CK. Received 10 U Insulin/ 1 amp D 50 Haldol/ativanKayexalate PR Calcium gluconate 1 g x 2. Patient pulled foleycatheter and NGT was unable to be placed..When arrived on MICU floor patient agitated and not responsiveto questions. Withdraws to
pain
DISEASE
.Past Medical History:1.
Hypertension
DISEASE
.2.
Chronic renal insufficiency
DISEASE
(with a baseline creatinineof 4 documented as far back at [**2140**]). The patient hasrefused a workup for this in the past.Social History:Patient living alone wife in rehab/[**Hospital1 1501**]. Per OMR: He is a former[**Company 2318**] worker. He use to drink heavily in his youth. No alcohol atall in the last 10years. No tobacco.Family History:NCPhysical Exam: t 97 BP 122/71 RR 19 02 91-100% HR 111GEN: Arousable agitatedHEENT: MM
dry
DISEASE
PERRL EOMINeck: JVP 6 cmCV: RRR [**2-15**] murmur at LLSBPulm: occ exp wheezes otherwise clear bilaterallyAbd: Admission Date: [**2164-10-1**] Discharge Date: [**2164-10-4**]Service: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:altered mental statusMajor Surgical or Invasive Procedure:intubationcentral line placementHistory of Present Illness:History of Present Illness: 88F w/ h/o
Grave's disease
DISEASE
Admission Date: [**2172-7-3**] Discharge Date: [**2172-7-13**]Service: MED
Allergies
DISEASE
:Amoxicillin / Aspirin / Clindamycin / Erythromycin Base /BactrimAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:
confusion
DISEASE
Major Surgical or Invasive Procedure:EGDBrief Hospital Course:
Respiratory failure
DISEASE
: The patient wasintubated and maintained on pressure support ventilation fromthe time of admission due to
respiratory failure
DISEASE
with bloodgas consistent with
hypoxia
DISEASE
.
Respiratory failure
DISEASE
in thispatient was presumably due to impending hemodynamic collapse.There was no clear evidence of
pneumonia
DISEASE
or other primarypulmonary process on chest x-ray or on examination. Thepatient had small right
pleural effusion
DISEASE
on admission anddeveloped left
pleural effusion
DISEASE
during her hospital stay butthese
effusions
DISEASE
were small and unlikely to contribute to
respiratory distress
DISEASE
. The patient was maintained on pressuresupport ventilation during her admission and oxygenation wasmaintained with acceptable parameters.
Hypotension
DISEASE
: The patient was
hypotensive
DISEASE
on admission withblood pressure as low as 60 over palpation in the emergencydepartment. This was most likely secondary to GI bleedAdmission Date: [**2146-7-21**] Discharge Date: [**2146-7-26**]Service: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:
Dyspnea
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Ms. [**Known lastname 4549**] is a [**Age over 90 **] y/o female with CAD/
CHF
DISEASE
afib
diabetes
DISEASE
presenting from clinic with
dyspnea
DISEASE
:[**2146-5-30**]: corneal transplant.10 days ago: increasing dyspnea/
orthopnea
DISEASE
5 days ago: Markedly worse
dyspnea
DISEASE
and
chills
DISEASE
can no longerwalk without
dyspnea
DISEASE
.1 day ago: shoulder
pain
DISEASE
relieved with lidocaine.At her baseline she is legally blind and ambulates with a caneAdmission Date: [**2139-6-3**] Discharge Date: [**2139-6-7**]Date of Birth: [**2059-2-14**] Sex: MService: MEDICINE
Allergies
DISEASE
:Sulfonamides / Quinine / ChloramphenicolAttending:[**First Name3 (LF) 4232**]Chief Complaint:
urosepsis
DISEASE
Major Surgical or Invasive Procedure:central line placement and removalHistory of Present Illness:This is an 80 y/o male with a h/o mental retardation GERD c/bsevere erosive
esophagitis prostate
DISEASE
CA s/p TURP withoutadditional treatment who presented to the ED with
fever
DISEASE
to 103subjective
dyspnea foul smelling
DISEASE
urine and
hypotension
DISEASE
withSBPs in the 70s. Pt is not communicative at baseline but didreport lower
abdominal pain
DISEASE
denied any CP SOB
cough
DISEASE
. Ptotherwise not able to give a more detailed history due tobaseline mental retardation..In [**Name (NI) **] pt was
hypotensive febrile
DISEASE
to 103. His lab values werenotable for an elevated WBC at 18.5 elevated transaminaseselevated lactate at 7.6 and an elevated Cr to 1.9. He was given5L NS and after placing a R femoral CVL started on Levophedfor BP support. He was empirically started on broad spectrumantibiotics of vancomycin levofloxacin and flagyl and admittedto the ICU for further care..In the ICU patient transiently required levaphed for pressuresupport. Infectious work up included blood cultures which areNGTD CXR which was negative RUQ U/S which was negative andurine culture with was positive for e. coli fluoroquinolonesensitive. He was maintained on vancomycin levofloxacin andflagyl. On this regimen the patient stablized as his BPreturned and levophed was discontinued his WBC decreased his
fever
DISEASE
resolved. His
renal failure
DISEASE
also resolved with fluidrescusitation. His LFTs trended down. His lactate came down..His ICU course was otherwise notable for a transient episode of
atrial fibrillation
DISEASE
which was broken with lopressor 5mg IV x 1and the patient was subsequently started on lopressor 12.5mg[**Hospital1 **]..His course thus far was also notable for platelets decreasedfrom 130 -Admission Date: [**2131-6-1**] Discharge Date: [**2131-6-15**]Service:
CSU
DISEASE
CHIEF COMPLAINT: Increasing
fatigue
DISEASE
decreasing appetite
and
weight loss
DISEASE
.HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is an 81-year-old womanwith multiple episodes of
congestive heart failure
DISEASE
with knownsignificant
mitral regurgitation
DISEASE
and chronic atrial
fibrillation
DISEASE
(on Coumadin for her
atrial fibrillation
DISEASE
)admitted preoperatively to come off of her Coumadin and beplaced on IV heparin while awaiting her INR to come back tonormal levels.The patient underwent a cardiac catheterization in [**2131-6-20**] which showed a cardiac index of 1.4 30% to 60% RCAlesion 4Admission Date: [**2131-6-1**] Discharge Date: [**2131-6-15**]Service: CARDIOTHORACIC
Allergies
DISEASE
:Heparin AgentsAttending:[**First Name3 (LF) 1283**]Chief Complaint:
Mitral regurgitation
DISEASE
Major Surgical or Invasive Procedure:1. Mitral valve replacement (#27 mosaic)History of Present Illness:81F c
mitral regurgitation
DISEASE
by TEE with symptoms of increasing
fatigue
DISEASE
decrease mobility
weight loss
DISEASE
. Evaluated asoutpatient with echo showing mild AI mod MR mild MS mod TRdilated LA and EF 40% and cardiac cath showing no significantCAD. She was admitted for preop heparin gtt.Past Medical History:1. MR2. AI3.
HTN
DISEASE
4.
COPD
DISEASE
5.
Hypercholesterolemia
DISEASE
6. Paroxysmal afib7. h/o L
retinal artery occlusion
DISEASE
8.
Pulmonary HTN
DISEASE
9. s/p
TAH
DISEASE
for endometrial CASocial History:NoncontributoryFamily History:NoncontributoryPhysical Exam:Afebrile VSSNAD alertNeck: no
bruits
DISEASE
no JVDHeart: Irregular [**2-25**] murmurLungs: CTABAbd: soft NT ND Admission Date: [**2118-12-1**] Discharge Date: [**2118-12-3**]Date of Birth: [**2037-12-24**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2485**]Chief Complaint:
weakness
DISEASE
and
cough
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:80 yo M with PMH of
HTN congenital deafness
DISEASE
and
osteoporosis
DISEASE
who presents with
fevers cough
DISEASE
and weakness. History is takenfrom patient and his home caregiver and also his HCP by phone..Patient was recently admitted after a fall and found to have aC7
fracture
DISEASE
. He was placed in a [**Location (un) 2848**] J collar and returned torehab. Per his caregiver over the last two days he has becomemore weak (not using his walker but requiring a wheelchair toget around) coughing and sounded Admission Date: [**2157-3-29**] Discharge Date: [**2157-4-8**]Date of Birth: [**2074-4-2**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2297**]Chief Complaint:
Subdural Hematoma
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:82F w/ h/o
multiple myeloma peripheral neuropathy
DISEASE
recentlyhospitalized on neuro service for work-up of multiple fallstransferred from [**Hospital3 2783**] with dx of right SDH. Thepatient was found down awake in the afternoon by staff atnursing home where she lives. She was admitted at [**Hospital1 18**] about 2weeks ago to work up the falls and at that time had negativeintracranial imaging (see detailed neurology note from [**2157-3-15**]).The falls were thought to be due to a combination of
neuropathy
DISEASE
post chemotherapy and mild
cervical spondylosis
DISEASE
and she wasdischarged to a nursing home. The current fall was
unwitnessed
DISEASE
and it is not clear if there was any LOC. Patient denies any
dizziness lightheadedness vertigo nausea/vomiting
DISEASE
. She alsocomes with a new dx of PNA possible aspiration PNA and wastreated with levaquin at OSH prior to arrival..In the ED initial vs were: T98.1 HR 80 BP 104/56 RR 14-16O2 99%RA. Patient was alert but somewhat confused. Head CTshowed no interval change in mid-line shift or size of SDH.Neurosurgery recommended 6-pack of plt's DDAVP Vit K (10mg IV)and 2L NS. Patient also received CTX for finding of
pneumonia
DISEASE
on CXR. Was admitted to MICU for q1H neuro checks and treatmentof
pneumonia
DISEASE
. At time of transfer VS 97.8 HR 80 Bp 96/41 RR22 O2 97% 3L NC RA sat of 93-94%Past Medical History:1. Multiple
myeloma
DISEASE
s/p chemotherapy followed by Dr. [**First Name (STitle) 2856**]at [**Company 2860**]. Seen by oncology for decreased counts on last admitand recommended to receive pulse steroids.2.
HTN
DISEASE
3.
Peripheral neuropathy
DISEASE
due to chemotherapy4. s/p both hips knees replacement and L ankle surgery5. OA6. s/p cholecystectomy7. s/p hysterectomy8. Frequent fallsSocial History:SH: Was living alone until recent falls with subdural requiringrehab - does not drive but pays own bills takes own meds andetc. Used to be a waitress. Has 2 grown children. Nocigarettes or EtOH.Family History:
FH
DISEASE
: NCPhysical Exam:T97.3 HR 84 BP 92/60 O2 Sat 97% 3L NCGeneral Appearance: No acute distress Thin very pleasant andcomfortable appearingEyes / Conjunctiva: PERRLHead Ears Nose Throat: NormocephalicCardiovascular: (S1: Normal) (S2: No(t) Normal Loud) No(t)S3 No(t) S4 No(t) Rub (Murmur: Systolic) At Erb's pointPeripheral Vascular: (Right radial pulse: Present) (Left radialpulse: Present) (Right DP pulse: Present) (Left DP pulse:Present)Respiratory / Chest: (Expansion: Symmetric) (Breath Sounds:Crackles : bilaterally)Abdominal: Soft
Non-tender Bowel
DISEASE
sounds present No(t)Distended No(t) Tender: No(t) ObeseExtremities: Right: Absent Left: AbsentSkin: Not assessedNeurologic: Attentive Follows simple commands Responds to:Verbal stimuli Oriented (to): place knows why she is inhospital Movement: Purposeful No(t) Sedated No(t) ParalyzedTone: Normal [**6-7**] full strength in UE bilaterally diminishedstrength 4/5 b/l in LE and nml cranial nervesPertinent Results:[**2157-3-28**] 09:20PM PT-15.1* PTT-33.5 INR(PT)-1.3*[**2157-3-28**] 09:20PM WBC-16.6*# RBC-2.69* HGB-9.2* HCT-25.5*MCV-95 MCH-34.3* MCHC-36.1* RDW-19.7*[**2157-3-28**] 09:20PM ALT(SGPT)-23 AST(SGOT)-41* ALK PHOS-67 TOTBILI-1.6*[**2157-3-28**] 09:39PM LACTATE-1.2[**3-28**] CT Head:IMPRESSION: Acute on chronic right subdural
hematoma
DISEASE
unchangedin comparisonstudy from five hours prior. 1-2mm of leftward shift of normallymidlinestructures.[**3-29**] CT Head:Evolution of
acute-on-chronic right subdural hematoma
DISEASE
withposterior layering of the acute component now tracking alongthe tentorium. There is no evidence for new
hemorrhage
DISEASE
increased mass effect or
edema
DISEASE
.[**4-2**] CT Head:There has been not significant change in size of an acute onchronic
subdural hematoma
DISEASE
but evolution of blood productswithin the
hematoma
DISEASE
is seen. There is no shift of minimal mass effect onsubjacent right occipital gyri remains seen and sulci areunchanged in configuration. The sulci are otherwise prominentcompatible with age-related involution. The ventricularconfiguration is unchanged. Again seen is scatteredperiventricular
white matter hypodensities
DISEASE
consistent withchronic
microvascular ischemia
DISEASE
.Surrounding soft tissues and osseous structures are stable inappearance.There is no
fracture
DISEASE
. Imaged paranasal sinuses and mastoid aircells are well aerated.IMPRESSION: Evolution of right subdural
hematoma
DISEASE
withoutevidence for new
hemorrhage
DISEASE
or increased mass effect. No new
hemorrhage
DISEASE
.[**3-28**] CT
C-spine
DISEASE
:1. No
fracture
DISEASE
or prevertebral soft tissue
swelling
DISEASE
.2. Multilevel degenerative changes predominantly at C5-6 andC6-7 unchanged in comparison to MRI [**2157-3-18**].[**3-28**] Echo:The left atrium is mildly dilated. The estimated right atrialpressure is 10-15mmHg. Left ventricular wall thickness cavitysize and regional/global systolic function are normal (LVEFAdmission Date: [**2124-7-21**] Discharge Date: [**2124-8-18**]Service: MEDICINE
Allergies
DISEASE
:AmlodipineAttending:[**First Name3 (LF) 898**]Chief Complaint:
COPD
DISEASE
exacerbation/Shortness of BreathMajor Surgical or Invasive Procedure:Intubationarterial line placementPICC line placementEsophagogastroduodenoscopyHistory of Present Illness:87 yo F with h/o
CHF COPD
DISEASE
on 5 L oxygen at baseline
tracheobronchomalacia
DISEASE
s/p stent presents with
acute dyspnea
DISEASE
over several days and
lethargy
DISEASE
. This morning patient developedan acute worsening in
dyspnea
DISEASE
and called EMS. EMS found patienttachypnic at saturating 90% on 5L. Patient was noted to betripoding. She was given a nebulizer and brought to the ER..According the patient's husband she was experiencing symptomsconsistent with prior
COPD flares
DISEASE
. Apparently patient waswithout
cough chest pain fevers chills orthopnea
DISEASE
PND
dysuria diarrhea confusion
DISEASE
and
neck pain
DISEASE
. Her husband is aphysician and gave her a dose of levaquin this morning..In the ED patient was saturating 96% on
NRB
DISEASE
. CXR did not revealany consolidation. Per report EKG was unremarkable. Laboratoryevaluation revealed a
leukocytosis
DISEASE
if 14 and lactate of 2.2.Patient received combivent nebs solumedrol 125 mg IV x1aspirin 325 mg po x1. Mg sulfate 2 g IV x1 azithromycin 500 mgIVx1 levofloxacin 750 mg IVx1 and Cefrtiaxone 1g IVx1. Patientbecame tachpnic so was trialed on non-invasive ventilation butbecame
hypotensive
DISEASE
to systolics of 80 so noninvasive wasremoved and patient did well on
NRB
DISEASE
and nebulizers for about 2hours. At that time patient became agitated hypoxic to 87% andtachypnic to the 40s so patient was intubated. Post intubationABG was 7.3/60/88/31. Propafol was switched tofentanyl/midazolam for
hypotension
DISEASE
to the 80s. Received 2L ofNS. On transfer patient VS were 102 87/33 100% on 60% 450 x18 PEEP 5. Patient has peripheral access x2..In the ICU patient appeared comfortable.Review of sytems:limited due to patient sedationPast Medical History:#
COPD
DISEASE
flare FEV1 40% in [**2120**] on 5L oxygen s/p intubation[**6-6**] s/p distal tracheal to Left Main Stem stents placed[**2118-6-9**]. Stents d/c'd [**2119-4-19**]. Tracheobronchoplasty performed [**6-6**] [**2119**]# CAD w/ atypical
angina
DISEASE
(cath [**2119**] - LAD 30% RCA 30% EF 63%)#
Dyslipidemia
DISEASE
#
Hypothyroidism
DISEASE
#
Hypertension
DISEASE
#
Hiatal hernia
DISEASE
# lacunar
CVA
DISEASE
# s/p ped struck -Admission Date: [**2165-9-23**] Discharge Date: [**2165-9-28**]Date of Birth: [**2114-1-13**] Sex: FService: MedicineHISTORY OF PRESENT ILLNESS: This is a 51-year-oldAfrican-American female with an extensive history of alcoholabuse class B child
cirrhosis
DISEASE
abstinent from alcohol since[**2165-3-26**]. She saw her primary care physician on [**9-20**]with complaints of a 5-day history of
general malaise abdominal
DISEASE
pain
DISEASE
and found to have white count of 26. Not notified untilthree days thereafter when she was told to go to the EmergencyRoom.She presented to the Emergency Department with abdominal
pain hypotensive
DISEASE
to 60/30 baseline systolic pressure of 90not responsive to intravenous fluids so started on dopamineand sent to the unit.On presentation her white count was 42 total bilirubinwas 7.2. Urinalysis positive for pan-sensitive Escherichiacoli. A subsequent abdomen ultrasound showed no
ascites
DISEASE
. Aright upper quadrant ultrasound showed
gallbladder inflammation
DISEASE
consistent with
cholecystitis
DISEASE
. Started on ceftriaxonevancomycin and Flagyl. She had an endoscopic retrogradecholangiopancreatography on the [**Hospital Ward Name **] with a common bileduct stent transient elevation of amylase and lipase status poststent. They were falling at the time of transfer. She wasweaned off pressors. Followed by Gastroenterology and GeneralSurgery.On the evening of transfer to the Medicine Service she wastolerating solids without
nausea
DISEASE
and
vomiting
DISEASE
. No
nausea
DISEASE
or
vomiting
DISEASE
since admission. Guaiac-positive but hematocrit wasstable. Review of systems was negative. A history of
esophageal varices
DISEASE
. A 3-grade II one grade 3 onesophagogastroduodenoscopy in [**2165-6-26**]. History of upper
gastrointestinal bleed
DISEASE
hemodynamically stable off pressors tofloor without problem.PAST MEDICAL HISTORY: 1. Alcoholic hepatitis cirrhosisAdmission Date: [**2114-7-12**] Discharge Date: [**2114-7-29**]Date of Birth: [**2040-9-4**] Sex: FService: CMEHISTORY OF PRESENT ILLNESS: The patient was originallyadmitted to the Vascular Surgery Service and was thentransferred three to four days later to the C-MED Service.This is a 73-year old female with
coronary artery disease
DISEASE
(status post coronary artery bypass grafting and multiplecardiac catheterizations and percutaneous interventions atoutside hospitals)
peripheral vascular disease
DISEASE
chronic
renal insufficiency
DISEASE
and
insulin-dependent diabetes mellitus
DISEASE
who was transferred to [**Hospital1 69**]from an outside hospital to the Vascular Surgery Service witha right lower extremity gangrenous ulceration. The reasonfor transfer was for possible vascular intervention.On arrival to the Vascular Surgery Service the patient's INRwas elevated as she had been on Coumadin for atrial
fibrillation
DISEASE
. She was given two units of fresh frozen plasmato reverse her
coagulopathy
DISEASE
and developed jaw
pain
DISEASE
(her
anginal
DISEASE
equivalent) and went into acute
cardiogenic
DISEASE
pulmonary
edema
DISEASE
. The patient was nearly intubated but improved with anitroglycerin drip and Natrecor.She was then transferred to the C-MED Service for furtherdiuresis and because her exercise tolerance test sestamibiobtained following her acute
cardiogenic pulmonary edema
DISEASE
showed reversible
anterior defects
DISEASE
as well as partiallyreversible
lateral wall defects
DISEASE
. Her creatine kinase andtroponin were flat at the time of the acute
cardiogenic
DISEASE
pulmonary edema
DISEASE
. The patient did report some baseline
shortness of breath
DISEASE
but felt that it was worse at the timeof transfer to C-MED Service. However at baseline thepatient can only walk 15 feet with a walker and is limited by
anginal pain
DISEASE
or
shortness of breath
DISEASE
. The patient did reportparoxysmal
nocturnal dyspnea orthopnea
DISEASE
and lower extremity
edema
DISEASE
in the past - but not currently. The patient uses 2liters of oxygen at home.PAST MEDICAL HISTORY:
Diabetes mellitus
DISEASE
.
Coronary artery diseaseAdmission
DISEASE
Date: [**2198-7-16**] Discharge Date: [**2198-7-28**]Date of Birth: [**2153-5-26**] Sex: FService: SURGERY
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 1234**]Chief Complaint:Leg pain
erythema
DISEASE
and
swelling
DISEASE
secondary to
infection
DISEASE
of leftfemoral-poplital bypassMajor Surgical or Invasive Procedure:1. Incision and drainage and pulse irrigation of left groin andleft above-knee popliteal site incisions with xxploration ofbypass graft ([**2198-7-16**])2. Excision of entire left common femoral artery-to-above-kneepopliteal artery bypass graftAdmission Date: [**2199-3-18**] Discharge Date: [**2199-3-22**]Date of Birth: [**2153-5-26**] Sex: FService: MEDICINE
Allergies
DISEASE
:Latex / doxycyclineAttending:[**First Name3 (LF) 2880**]Chief Complaint:
Chest pain
DISEASE
and
nausea
DISEASE
for 5 daysMajor Surgical or Invasive Procedure:Cardiac Catherization [**2199-3-20**]History of Present Illness:Patient is a 45 yo F with
PVD DM HL HTN
DISEASE
and
OSA
DISEASE
. no knownCAD no history cath who presents with
chest pain
DISEASE
and pressurefor 5 days. Patient was last in her usual state of health 5 daysprior to admission when she began to feel an intense chestpressure and heaviness in the left chest radiating up to the jawwhile walking to her car. At this time she also felt intense
nausea
DISEASE
. The
pain
DISEASE
and
nausea
DISEASE
abated on its own but recurred moreintensely that night accompanied with
vomiting
DISEASE
. At home shetook one of her boyfriend's nitroglycerin which brought aboutpartial relief of
pain
DISEASE
. She continued over the weekend to have
pain nausea and vomiting
DISEASE
recurring which was relieved with herboyfriend's nitroglycerin. In total she reports taking 7 nitrosfor these episodes over the weekend. She had progressive
fatigue
DISEASE
as the days progressed and on day of presentation took ashower after which she felt extreme pronounced
fatigue
DISEASE
whichprompted her to present to the hospital. She reports worsening
orthopnea
DISEASE
and DOE. Also while she was on full dose aspirin dueto
PVD
DISEASE
has not taken it while being on coumadin..In the ED VS 98.4 83 104/64 16 100% RA EKG was read as nonacute and CXR was normal. Troponin and ckmb were neg x2. Patientunderwent stress MIBI which showed new partially reversibleinferior wall mild perfusion defect.Past Medical History:PMH:
asthma
DISEASE
diabetes
DISEASE
type 2
anxiety
DISEASE
LLE DVT
PVD
DISEASE
HLD
HTN
DISEASE
OSA
DISEASE
.
PSH
DISEASE
:b/l angiogramsL knee surgery x2appendectomytonsillectomyL fem-AK [**Doctor Last Name **] [**2198-6-11**] graft removal[**7-17**]vein patch angioplasty of L CFA/[**Doctor Last Name **] [**7-19**]washout and complex wound closure [**7-26**].Social History:Moving in with her boyfriend. She has one child. She isunemployed. Had a recent house fire and is currently living inher daughter's house.Tobacco history: 2ppd for past 25 yrs former 1.5ppd newly quiton vareniclineFormer cocaine use. (denies use for many years)Drinks 5-6 drinks on weekends.Hx of domestic violence.Family History:Mother had an
abdominal aortic aneurysm
DISEASE
status post repair MIin her mid 50s
carotid stenosis cervical cancer
DISEASE
coronary
artery disease
DISEASE
other [**Month/Year (2) 1106**] lesions which were stented. Shedied due to complications of a procedure. The patient's fatherdied young. The patient has one cousin with
cervical cancer
DISEASE
. Hermaternal grandmother had an MI in her 60s. Maternal grandfatherwith MI
hypertension
DISEASE
and
hypercholesteremia
DISEASE
.Physical Exam:PHYSICAL
EXAM
DISEASE
ON ADMISSION:VS: T98.3 BP125/71 HR69 RR18 O2sat 99%RAGENERAL: WDWN in NAD. Oriented x3. Mood affect appropriate.HEENT: NCAT. Sclera anicteric. PERRL EOMI. Conjunctiva werepink no pallor or
cyanosis
DISEASE
of the oral mucosa. No xanthalesma.NECK: Supple with no JVDCARDIAC: RRR normal S1 S2. No m/r/g. No thrills lifts. No S3or S4.LUNGS: No
chest wall deformities scoliosis
DISEASE
or
kyphosis
DISEASE
. Respwere unlabored no accessory muscle use. CTAB no crackles
wheezes or rhonchi
DISEASE
.ABDOMEN: Soft NTND. No HSM or
tenderness
DISEASE
. Abd aorta notenlarged by palpation. No
abdominial bruits
DISEASE
.EXTREMITIES: No c/c/e. No
femoral bruits
DISEASE
.SKIN: No
stasis dermatitis ulcers
DISEASE
scars or
xanthomas
DISEASE
noarterial
ulcers
DISEASE
PULSES:Right: radial 2Admission Date: [**2148-1-2**] Discharge Date: [**2148-1-6**]Date of Birth: [**2085-9-6**] Sex: FService: MEDICINE
Allergies
DISEASE
:Lisinopril / Bupropion / Rosiglitazone DerivativesAttending:[**First Name3 (LF) 2736**]Chief Complaint:
dyspnea
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:Mrs. [**Known firstname 2894**] [**Known lastname 2895**] is a very nice 62 year-old woman withsignificant past medical history of diabtes
mellitus
DISEASE
type 2
hypertension hyperlipidemia
DISEASE
CAD s/p CABG who comes with threeweeks of
shortness of breath and dyspnea
DISEASE
on excertion. Patientstates that she is not very active at home given baseline
shortness of breath
DISEASE
which is thought to be secondarely to her
heart disease
DISEASE
and COPD/Asthma but she is able to do 1 flight ofstairs with difficulty. However during the last 3 weeks she hasnoted progressive SOB with less activity such as 10 steps. Shedenies any
nausea vomit cough chest pain palpitations
DISEASE
wheezing
DISEASE
associated with the SOB. She still uses either 1 or nopillows at night and can lie flat without difficulty. Sheweights herself daily and has been with diet to try to losewieght. There have been no sick contacts and she denies any
fever chills rigors cough rhinorrhea arthralgias
DISEASE
muscle
pains diarrhea dysuria
DISEASE
urinary frequency. She went to see herendocrinologist that follows her for her
diabetes mellitus
DISEASE
andwas asked to come to our emergency room. Her VS at that timewere: BP 167/71 mmHg P 72 BPM SpO2 O2 93% oN
RA
DISEASE
..Per patient's report she had a stress test done in [**Month (only) **] lastyear but could not walk for more than a couple of minutes.There was no imaging done. She had not had a cardiac cath sinceher CABG..In the ER her initial VS were BP 163/61 mmHg P63 BPM RR 1794% on
RA
DISEASE
T 98.4 F. She had an ECG that showed occasional PVCswith
LVH
DISEASE
by Sokolow-[**Doctor Last Name **] cirteria with TWI in I II avL andV5-V6 as well as Admission Date: [**2196-10-4**] Discharge Date: [**2196-10-9**]Date of Birth: [**2129-4-3**] Sex: FService: [**Hospital Unit Name 196**]
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Last Name (NamePattern1) 1171**]Chief Complaint:SOBMajor Surgical or Invasive Procedure:MICU admissionCardiac catheterizationDialysisHistory of Present Illness:67yo female with CAD DMII ESRD who was initially admitted forSOB on [**2196-10-4**]. Pt complained of increased SOB after dialysisand was transferred to the MICU for closer monitoring ofrespiratory status. CXR was consistent with
CHF
DISEASE
and ECG showedsigns of mild ST
depression
DISEASE
in I aVL and poor R waveprogression. Pt ruled in for NSTEMI with CK peak of 207 andtrop peak of 2.22 while in the MICU. Pt denied CP
palpitations
DISEASE
SOB.Past Medical History:DM II
ESRD
DISEASE
- on HD T Th SCAD s/p NSTEMI [**10-8**] s/p LAD stent LCx stent at [**Hospital1 2025**] on [**10-5**]
uremic pericarditis
DISEASE
tamponade
DISEASE
s/sp
pericardiocentesis
DISEASE
2'[**93**]thyroid nodule
tachyarrythmia
DISEASE
R arm AVG s/p thrombectomySocial History:Primarily Italian speaking women who lives by herself. Daughtercomes to visit 3-7x/week and patient also has son who isinvolved and may take her in. Remote smotking history.Family History:Non-contributory.Physical Exam:PE:VS: T: 97.9 BP: 147/53 HR: 65 RR: 20 SaO2: 98% on 4LGen: pleasant elderly women in NADHEENT: Pupil unequal dysconjugate gaze with R eye. mmmNeck: supple no LAD JVP approximately 7cmCV: RRR III/VI SEM at apexChest: crackles half way up chest/back bilaterallyAbd: soft NT ND BSAdmission Date: [**2144-9-4**] Discharge Date: [**2144-9-7**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2901**]Chief Complaint:
chest pain
DISEASE
Major Surgical or Invasive Procedure:Cardiac CatherizationHistory of Present Illness:79 yo male w/ past medical history significant for
myasthenia
DISEASE
[**Last Name (un) 2902**] complains of [**9-22**] pressure like substernal
chest pain
DISEASE
starting yesterday while lying in bed lasting 2 hoursunrelieved by tylenol or aspirin. Associated with
diaphoresis
DISEASE
.No
shortness of breath
DISEASE
. Resolved on its own. Pt had recurrenceof
pain
DISEASE
this morning upon awakening went to PMD's office andwas noted to have 1-[**Street Address(2) 1766**] elevations in V2-V3 was givenaspirin and sent to the ED. On arrival at ED he had [**8-22**] chest
pain
DISEASE
with 0.[**Street Address(2) 1755**] elevation in V2 1 mm elevation in V3 0.5mmm elevation in V4 with TWI in V1-V4. He was taken to the cathlab and found to have a 90%
LAD occlusion
DISEASE
that was stented anda non intervenable diffusely diseased RCA. He was also noted tohave normal right sided heart pressures with an oxygen step upin the right atrium.He denied doe pnd
orthopnea dyspnea edema palpitations
DISEASE
syncope
DISEASE
or
presyncope
DISEASE
.Past Medical History:
myasthenia
DISEASE
[**Last Name (un) 2902**] dx [**2138**]post
herpetic neuralgia
DISEASE
left leg
prostate cancer
DISEASE
s/p xrt [**2136**] and resection (TURP) [**2133**]h/o
thrombocytopenia
DISEASE
resolvedno history of cad
diabetes hypercholesterolemia
DISEASE
or
hypertension
DISEASE
Social History:former chemical engineer married with four children nosmoking occ alcohol.Family History:mother: DMPhysical Exam:Temp afebrile BP 163/82 Pulse 54 Resp 12 O2 sat 99%RAGen - Alert no acute distressHEENT - NCAT PERRL extraocular motions intact anictericmucous membranes moist hard of hearing L ear.Neck - 2Admission Date: [**2134-12-12**] Discharge Date: [**2135-1-3**]Date of Birth: [**2069-2-21**] Sex: MService: Cardiothoracic ServiceHISTORY OF PRESENT ILLNESS: The patient is a 68 year old manwith a two week history of increasing
shortness of breath
DISEASE
admitted to the [**Hospital6 2910**] on [**12-6**]where he ruled in for an
myocardial infarction
DISEASE
. The patientwith known
cardiomyopathy
DISEASE
of unclear etiology with known
coronary artery disease
DISEASE
by MIBI echocardiogram scheduled foran elective catheterization but had increasing
shortness of
breath and dyspnea
DISEASE
on
exertion
DISEASE
therefore admitted prior tohis cardiac catheterization and ruled in for non-Q wave
myocardial infarction
DISEASE
. His catheterization at [**Hospital6 2911**] showed 50% left main left main 80% left anteriordescending 70% right coronary artery with an ejectionfraction of 20%. The patient was in
congestive heart failure
DISEASE
at the time. He was started on Dobutamine with relief ofsymptoms and was transferred to [**Hospital6 2018**] for coronary artery bypass grafting. Catheterizationdone at that time also showed an aortic valvular area of 0.8cm squared. He has a history of
syncopal
DISEASE
episodes.Therefore his catheterization was to be repeated afterarrival at [**Hospital6 256**].PAST MEDICAL HISTORY: Significant for
diabetes mellitus
DISEASE
hypertension cardiomyopathy
DISEASE
elevated lipids.PAST SURGICAL HISTORY: Significant for
penile
DISEASE
prosthesis andL4-5 fusion.MEDICATIONS ON ADMISSION: Insulin 70/30 60 units b.i.d.Admission Date: [**2197-4-4**] Discharge Date: [**2197-4-8**]Date of Birth: [**2157-1-25**] Sex: FService:ADMISSION DIAGNOSES:1. Chronic
pelvic pain
DISEASE
.2. Enlarged multifibroid uterus.3. Endometriosis.DISCHARGE DIAGNOSES:1. Chronic
pelvic pain
DISEASE
.2. Enlarged multifibroid uterus.3. Endometriosis.INDICATIONS FOR ADMISSION: The patient had a longstandinghistory of
endometriosis
DISEASE
with priory surgery dating back to[**2186**]. She had gone on to develop an enlarged 12-week to15-week size multifibroid uterus along with additional cysticchange of the ovary. She was not planning to have childrenand when consulted on the various options agreed to surgerywith a goal of removing the uterus and adnexa in an effort tomanage her chronic
pelvic pain
DISEASE
and
bleeding
DISEASE
.BRIEF SUMMARY OF HOSPITAL COURSE: On the day of admissionshe was taken to the operating room and underwent extensivesurgeryvia laparotomy. The procedure was complicated by a leftureteral transection which was repaired under the auspices ofthe Urology Service ( a separate Operative Note was dictatedfor that. Additionally due to the intense fibrotic scarringsecondary to her
endometriosis
DISEASE
consultation was requestedfrom Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 2920**] [**Doctor Last Name 1022**] who graciously assisted in completingdissection of the uterus and adnexa ultimately resulting ina total abdominal hysterectomy and bilateralsalpingo-oophorectomy which confirmed endometriotic changes.There was a great deal of dissection involved in separatingthe posterior uterine surface from the bowel but no entryinto the bowel occurred.Her intraoperative course was punctuated by receipt of twounits of transfused packed red blood cells. Due tocontinuing
anemia
DISEASE
she received an additional three units on[**2197-4-7**]. Her lowest hematocrit appeared to be 24 and atdischarge had risen to 27.9.Her postoperative course basically was smooth. She didreceive intravenous antibiotics. A urinary stent had beenplaced in the left ureter which was to be removedapproximately 10 days postoperatively in the urologist'soffice. She remained stable throughout the course and beganto pass gas within two to three days and had resumption ofbowel function. Pain control was managed with narcoticanalgesics.She was discharged on her sixth postoperative day in stablecondition. She was afebrile with a hematocrit of 27.9. Shewas to continue replacement iron and was to be seen thefollowing week for removal of the urinary catheter. She wassubsequently seen also in my office for scheduledpostoperative appointments and was making a uncomplicatedrecovery at that point.FINAL DISCHARGE DIAGNOSES:1. Chronic
pelvic pain
DISEASE
.2. Multifibroid uterus.3. Endometriosis (severe stage 4).DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient will continueto be followed at the [**University/College **] office of [**Hospital1 2921**]. [**First Name11 (Name Pattern1) 2922**] [**Last Name (NamePattern4) 2923**] M.D. [**MD Number(1) 2924**]Dictated By:[**Last Name (NamePattern4) 2925**]MEDQUIST36D: [**2197-8-29**] 22:03T: [**2197-9-2**] 04:46JOB#: [**Job Number 2926**]Admission Date: [**2148-4-2**] Discharge Date: [**2148-4-16**]Date of Birth: [**2069-6-14**] Sex: MService: NEUROLOGY
Allergies
DISEASE
:PhenobarbitalAttending:[**First Name3 (LF) 2927**]Chief Complaint:transferred for
seizure
DISEASE
managementMajor Surgical or Invasive Procedure:IntubationLong Term EEG monitoringHistory of Present Illness:78yo RH M h/o brain
tumor
DISEASE
s/p R frontal resection in [**2132**] CAD
hyperlipidemia prostate cancer
DISEASE
s/p XRT and
seizure disorder
DISEASE
whois transferred for increasing
seizures
DISEASE
..He initially presented to OSH on [**3-29**] with Unit No: [**Numeric Identifier 2929**]Admission Date: [**2148-2-5**]Discharge Date: [**2148-2-10**]Sex: FService: NSUHISTORY OF PRESENT ILLNESS: The patient is an 81-year-oldwoman status post a fall with a right-sided subdural
hematoma
DISEASE
. The patient had an elevated INR secondary toCoumadin for
atrial fibrillation
DISEASE
. She was taken emergentlyto the OR for a craniotomy for evacuation of this right-sided
subdural hematoma
DISEASE
. A CT scan showed a large right-sided
subdural hematoma
DISEASE
measuring 1.5 cm in size with midline shiftand subfalcine herniation. Laboratories on admissionrevealed a white count of 7.5 crit 31.1 platelets 375000.Sodium 134 potassium 6.4 chloride 100 C02 24 BUN 11creatinine 0.8 glucose 93. INR on admission was 1.4.PHYSICAL EXAMINATION: The patient on physical examinationwas intubated and sedated. HEENT: The patient's right pupilwas dilated and sluggishly reactive. Respiratory raterevealed coarse breath sounds. Cardiovascular revealed S1and S2 A paced. The abdomen was soft positive bowelsounds. Extremities: She has some left upper extremity
swelling
DISEASE
.HOSPITAL COURSE: She is status post a right subdural
hematoma
DISEASE
evacuation without intraoperative complications.She was monitored in the ICU. On postoperative check she wasalert and attentive opening her eyes following commandstimes four although still intubated. She had apostoperative CT which was stable. Her blood pressure waskept less than 160 and she was weaned to extubate. Thepatient had
bradycardia
DISEASE
during surgery so EP came andinterrogated her pacemaker. She was in the DDD mode and herpacer was functioning appropriately.On [**2148-2-7**] the patient had a repeat head CT whichwas stable. The patient was successfully extubatedfollowing commands times four. PT and OT were ordered toevaluate the patient and the patient remained neurologicallystable. She was transferred to the regular floor on[**2148-2-7**]. She was in stable condition. She was evaluated byphysical therapy and occupational therapy and found torequire a short rehabilitation stay prior to discharge home.MEDICATIONS:1. Famotidine 20 mg p.o. twice daily.2. Dilantin 100 mg p.o. three times daily.3. Heparin 5000 units subcutaneously twice daily.4. Lasix 20 mg p.o. daily.5. Sotalol 80 mg p.o. twice daily.6. Valsartan 40 mg p.o. daily.7. Colace 100 mg p.o. twice daily.8. Diltiazem 90 mg p.o. four times daily.9. Isosorbide 20 mg p.o. twice daily.10. Albuterol inhaler one to two puffs every six hours as needed.11. Ipratropium bromide one nebulizer inhaler every six hours as needed for
wheezing
DISEASE
.The patient remained neurologically stable. She wasevaluated by PT and OT and felt to require rehabilitation.The staples can be removed on postoperative day number ten.The patient had the surgery on [**2148-2-5**].CONDITION ON DISCHARGE: Stable.FOLLOW UP: The patient will follow-up with Dr. [**Last Name (STitle) 739**]in two weeks with a repeat head CT.ADDENDUM: On repeat head CT the patient also had a left-sided chronic
subdural hematoma
DISEASE
which did enlarge once theright-sided subdural
hematoma
DISEASE
was evacuated and that willrequire further evaluation with repeat head CT in two weekswith Dr. [**Last Name (STitle) 739**]. [**Name6 (MD) **] [**Name8 (MD) 739**] MD [**MD Number(2) 2930**]Dictated By:[**Last Name (NamePattern1) **]MEDQUIST36D: [**2148-2-9**] 16:16:53T: [**2148-2-9**] 16:41:55Job#: [**Job Number 2931**]Admission Date: [**2170-9-1**] Discharge Date: [**2170-9-5**]Date of Birth: [**2114-1-13**] Sex: FService: MEDICINE
Allergies
DISEASE
:Penicillins / Levofloxacin / Codeine / Bactrim DsAttending:[**First Name3 (LF) 1580**]Chief Complaint:altered mental statusMajor Surgical or Invasive Procedure:noneHistory of Present Illness:56F with EtOH
cirrhosis
DISEASE
initially found unresponsive in AM 3dago. FSBGs 200s no e/o sz and initially intubated on arrivalto the ED for airway protection. CT head was negative LPdeferred [**12-28**]
coagulopathy
DISEASE
. Pt. with h/o of poor compliance with
encephalopathy
DISEASE
meds and mutliple admissions in past for AMSthough pt. reports compliance with meds and [**12-29**] BMS/day. Pt. wasextubated yesterday without complication and has had no e/owithdrawal on this admission (per pt. last ETOH in [**Month (only) **]). Pt.with dirty U/A on admit and sputum cx. growing GAdmission Date: [**2184-1-30**] Discharge Date: [**2184-2-5**]Date of Birth: [**2120-1-2**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2932**]Chief Complaint:altered mental statusMajor Surgical or Invasive Procedure:central line placementHistory of Present Illness:64 year old male with a past medical history significant for
atrial fibrillation
DISEASE
and
bipolar disorder
DISEASE
presented with
fever
DISEASE
rigors
DISEASE
and
sore
DISEASE
throat. Mr. [**Known lastname 2933**] states that he developedsore throat and
cough
DISEASE
productive of grayish-yellow sputum 2 daysago. He took some aspirin and cepachol without significantrelief. On the day of admission his wife noted that he wasconfused warm and breathing shallowly. In the ED rectal temp Admission Date: [**2185-7-6**] Discharge Date: [**2185-7-8**]Date of Birth: [**2120-1-2**] Sex: MService: MEDICINE
Allergies
DISEASE
:Pneumovax 23Attending:[**First Name3 (LF) 2297**]Chief Complaint:
weakness achyness
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:. Boiseau is a pleasant 65 yo man with paroxysmal atrial
fibrillation bipolar disorder
DISEASE
and h/o EtOH abuse who presentedto the ED today with complaints of R arm
pain
DISEASE
achiness andAdmission Date: [**2186-5-2**] Discharge Date: [**2186-5-10**]Date of Birth: [**2120-1-2**] Sex: MService: MEDICINE
Allergies
DISEASE
:Pneumovax 23Attending:[**First Name3 (LF) 689**]Chief Complaint:
Diarrhea Weakness Pneumonia
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness: 66M hx pAF C diff recent at St E for PNA home from rehab xfew days wife noted sats down (95-96 on 2 L NC up to 3-4 L thisAM) more letharagic poor POs today 102F recent tx for Cdiff now increased
volume diarrhea
DISEASE
..Per records from [**Hospital 2940**] admission [**2186-3-29**] treated for C diffwith Flagyl in addition to Vanc/Zosyn for PNA. Blood cxpositive for
VRE
DISEASE
started on Linezolid. BAL grew Enterobactercloacae (treated with Zosyn). Pt also had
pancytopenia
DISEASE
hadmarrow bx penia attributed to
infection
DISEASE
vs fecainide which wasdiscontinued..In [**Name (NI) **] pt noted to have a
cough
DISEASE
crackles R base BP 160s downto 80s abd soft bilat LE
edema
DISEASE
. Vitals: 103.8R HR 90s160/90 sat 94 on 5L. BP mid 80s given 3 L NS. Tylenol broughttemp down to 101.8. Pt noted to be confused at times. Lactate2.4. CXR with RLL infilrate. UA neg. Antibiotics given:CTX/Vanc/Levaquin/Flagyl. FULL Code..On arrival to the ICU pt was in NAD speaking in fullsentences A&Ox3..Review of sytems:(Admission Date: [**2186-6-14**] Discharge Date: [**2186-6-21**]Date of Birth: [**2120-1-2**] Sex: MService: MEDICINE
Allergies
DISEASE
:Pneumovax 23Attending:[**First Name3 (LF) 800**]Chief Complaint:Mental
Status Changes/Hypoxia
DISEASE
Major Surgical or Invasive Procedure:Lumbar PunctureHistory of Present Illness:This is a 66 year old male with
hepatitis C
DISEASE
history of alcoholabuse
bipolar affective disorder atrial fibrillation
DISEASE
and arecent admission to [**Hospital1 18**] for
pneumonia
DISEASE
who was transferred froman outside hospital where he had presented with mental statuschanges and
dyspnea
DISEASE
. The patient was not able to give a fullaccount of the circumstances leading to his admission but perhis family he had increasing
dyspnea
DISEASE
and
confusion
DISEASE
startingapproximately five days prior to presentation. He may have had
chills
DISEASE
but no
fevers
DISEASE
and he was noted to be extremely fatigued.At the outside hospital he was
febrile
DISEASE
bradycardic
hypotensive
DISEASE
non-verbal pale and not following commandsreliably. After initial lab results did not reveal a clearsource of his illness he was transferred to [**Hospital1 18**] for furthermanagement.In the [**Hospital1 18**] ED initial vitals were T 100 BP 89/40 HR 45 RR16 94% on 2L. Over his ED course he became progressively morehypoxic and eventually required 4.5L of O2 by nasal cannula tomaintain a sat of 92%. He was initially bradycardic with ratesin the 40's but this spontaneously improved to 70s-90s withoutinterventions. His SBP's improved to 90's-100's with 2L IVF.His chest radiograph revealed a right middle lobe infiltratewhich he had recently been treated for at [**Hospital1 18**] (admission until[**2186-5-10**]). He received vancomycin and levofloxacin for apossible
pulmonary infection
DISEASE
as well as IV metronidazole as thepatient had
diarrhea
DISEASE
and had C diff in [**Month (only) 958**]. He wastransferred to the ICU for further management.Past Medical History:-
Atrial Fibrillation
DISEASE
- History of
clostridium difficile
DISEASE
-
Bipolar Affective
DISEASE
Disorder- History of
hepatitis
DISEASE
C- History of
rheumatic heart disease
DISEASE
- History of right middle cerebral artery aneurysm clipped in[**2167**] at [**Hospital6 1708**]- History of
pernicious anemia
DISEASE
-
Gastroesophageal reflux disease
DISEASE
Social History:He lives with his wife. [**Name (NI) **] has a history of alcohol abuse butthis was greater than twenty years ago. He stopped smokingafter his previous hospitalization (about one month prior topresentation) but previously had a 40 pack year history. He hadbeen discharged from his last hospitalization with oxygen buthad not been using this prior to admission.Family History:His father had
lung cancer
DISEASE
and his mother had
congestive heart
failure
DISEASE
.Physical Exam:On Presentation to ICU
VS - T 96.2Admission
DISEASE
Date: [**2186-6-23**] Discharge Date: [**2186-7-6**]Date of Birth: [**2120-1-2**] Sex: MService: MEDICINE
Allergies
DISEASE
:Pneumovax 23Attending:[**First Name3 (LF) 905**]Chief Complaint:
pneumonia hypoxia hypotension
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:The pt is a 66-yo man with paroxysmal
atrial fibrillation
DISEASE
hepatitis C
DISEASE
h/o
C.diff colitis
DISEASE
and a recent
pneumonia
DISEASE
discharged [**2186-6-21**] on Vanc / Zosyn who was found by his familyto be more hypoxic and tired than usual so they brought him intothe ED. His wife found him to be more sick than usual at about4pm today needing more supplemental O2 than prior (2L --Admission Date: [**2186-8-7**] Discharge Date: [**2186-8-26**]Date of Birth: [**2120-1-2**] Sex: MService: SURGERY
Allergies
DISEASE
:Pneumovax 23Attending:[**First Name3 (LF) 2836**]Chief Complaint:c diff
colitis
DISEASE
Major [**First Name3 (LF) 2947**] or Invasive Procedure:noneHistory of Present Illness:HPI: The patient is a 66-year-old male who is known to have C.
difficile colitis
DISEASE
and was admitted to the Gold surgery servicein3/[**2186**]. He was referred to [**Hospital1 18**] for
weakness rigidity
DISEASE
lethargy
DISEASE
decreased level of interaction and
anorexia
DISEASE
. About aweek ago he began having
diarrhea
DISEASE
. He has been on metronidazole500mg po BID for several weeks.In the ED his initial vital signs were 97.3 129 146/93 18 99RA.His heart rate stabilized to 80-90s after 2 liters of IVF. Ataround 23:30 he became acutely
hypotensive
DISEASE
to SBP of 80s-90smaintaining his heart rate in the 90s. ICU bed was arranged forclose monitoring.Past Medical History:- Paroxysmal
Atrial Fibrillation
DISEASE
- History of C diff
colitis
DISEASE
-
Bipolar Affective
DISEASE
Disorder- History of resolved
hepatitis B
DISEASE
- History of
rheumatic heart disease
DISEASE
- History of right MCA aneurysm clipped in [**2167**] at [**Hospital1 112**]- History of
pernicious anemia
DISEASE
-
Gastroesophageal reflux disease
DISEASE
Social History:He lives with his wife. Questionable history of alcohol abuse(did abuse alcohol Admission Date: [**2136-1-25**] Discharge Date: [**2136-2-3**]Service: MEDICINE
Allergies
DISEASE
:NitroglycerinAttending:[**First Name3 (LF) 30**]Chief Complaint:
palpitations chest pain abdominal pain
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:[**Age over 90 **]y/o Russian speaking F with CAD severe AS
HTN
DISEASE
and atrial
fibrillation
DISEASE
presenting with
chest pain
DISEASE
SOB palpatations and
abdominal pain
DISEASE
. She was in her USOH until the past week per thedaughter and this includes intermittant
chest pain
DISEASE
andpalpatations. Over the past week however she has complained ofdull transient upper
abdominal pain
DISEASE
especially with food andmore frequent episodes of
chest pain
DISEASE
and palpatations. Her chest
pain
DISEASE
can occur either with exertion (walks at home with a caneor walker) or at rest. She denies any recent
fevers chills
DISEASE
sick contacts
N/V diarrhea weakness paresthesias
DISEASE
visual/auditory changes
dysuria rash
DISEASE
or mental statuschanges. She has mild
orthopnea
DISEASE
and DOE both of which arebaseline but has been mildly more SOB this week..In the ED she was found to be in
Afib
DISEASE
w/ RVR up to the 130s andreceived 10mg IV diltiazem x 3 and given 30mg PO diltiazem. ARUQ ultrasound revealed
dilated biliary and pancreatic ducts
DISEASE
andher
pain
DISEASE
was controlled with IV morphine 0.5mg x 2. ERCP wascontact[**Name (NI) **] and plan to take the patient for an exam in the AM..On the floor the patient remained tachycardic and she remainedtachypneic. The MICU was called to evaluate the patient forpossible admission given her high nursing needs. On evaluationthe patient Admission Date: [**2136-5-25**] Discharge Date: [**2136-5-26**]Service: MEDICINE
Allergies
DISEASE
:NitroglycerinAttending:[**First Name3 (LF) 2297**]Chief Complaint:cough/hypoxiaMajor Surgical or Invasive Procedure:noneHistory of Present Illness:The patient is a [**Age over 90 **] year old woman with history of severe aorticstenosis
atrial fibrillation
DISEASE
chronic
anemia
DISEASE
who presents fromher
chest and abdominal pain
DISEASE
with worsening
cough
DISEASE
for the past 2days. The
abdominal pain
DISEASE
and difficulty breathing worsened overthe last four hours prior to coming to the hospital..In the ED her initial vital signs were 101.8(rectal) 140 113/9043 97%4L. Peripheral IVs were placed and 2L of NS saline wasgiven in total. She received ceftriaxone/levofloxacin for CAP. Abedside u/s was negative for free fluid. She also received 1dose of lopressor (2.5mg) without effect. Her
pain
DISEASE
improved butblood pressure started to decrease 90 HR 105 Sat 100 on NRBstill tachypneic Admission Date: [**2183-7-23**] Discharge Date: [**2183-7-30**]Date of Birth: [**2105-12-3**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2969**]Chief Complaint:
Left non-small cell lung cancer
DISEASE
diagnosed in 6/[**2182**].Major Surgical or Invasive Procedure:[**2183-7-23**]: bronchoscopy and mediastonoscopy[**2183-7-25**]: LUL segmentectomy LLL wedge resectionHistory of Present Illness:Mr. [**Known lastname 2970**] is a 77-year-old gentleman referred by Dr. [**First Name4 (NamePattern1) **][**Last Name (NamePattern1) 1391**] to Dr. [**Last Name (STitle) **] for advice and options regarding a
carcinoma of the lung
DISEASE
detected during recent hospitalization for
coronary disease
DISEASE
and a large
aortic aneurysm
DISEASE
in [**2183-5-8**]. Alesion in the left lung was discovered in the upper lobe and aneedle biopsy confirmed
non-small cell carcinoma
DISEASE
. He underwenta PET scan which showed extreme
hypermetabolism
DISEASE
with an SUV of17 at the site of the lung primary lesion. There is sparseuptake within the mediastinum not considered of pathologicsignificance as well as active
inflammation
DISEASE
around theabdominal graft.He presented to [**Hospital1 18**] on [**2183-7-23**] for an operation to address hisleft
non-small cell lung cancer
DISEASE
.Past Medical History:Significant for
coronary disease
DISEASE
statuspost an
infarction
DISEASE
. He has
aortic aneurysm
DISEASE
increased serumcholesterol prostate cancer and
carcinoma of the sigmoid
DISEASE
colon.PAST SURGICAL HISTORY: Sigmoid colectomy in [**2171**] radicalprostatectomy in [**2169**] and the tube graft repair of hisabdominal
aortic aneurysm
DISEASE
.Social History:He has substantial prior smoking history just recently quit.He has no active alcohol issues.Physical Exam:VITAL SIGNS: Weight of 148 pounds. He is afebrile bloodpressure 140/83 pulse 74 and regular and room air saturationis95%.LUNGS: His lung fields are surprisingly clear.HEART: Regular rhythm and rate without murmur or gallop.NECK: There were no
carotid bruits
DISEASE
.ABDOMEN: Soft and nontender with good healing ridge along thewound.EXTREMITIES: He has no
peripheral edema
DISEASE
.Brief Hospital Course:The patient presented to [**Hospital1 18**] on the day of planned surgery.He was noted to have significant
bradycardia
DISEASE
prior to startingthe operation. He did undergo a flexible bronchoscopy andmediastinoscopy that was complicated by substantial
intraoperative bleeding
DISEASE
. He was subsequently ruled out for acardiac event and remainedhemodynamically and neurologically stable on POD#1. On HD#3 thedecision was made to proceed with a segmental resection giventhe T2 size of the lesion and his limited baseline lungfunction. Please refer to both operative notes of [**2183-7-23**] and[**2183-7-25**] for further details of the procedures. An epidural wasplaced for
postoperative pain
DISEASE
control on [**2183-7-25**]. Two left-sidedchest tubes were placed intraoperatively and a post-operativechest radiograph showed a moderate left sided
pneumothorax
DISEASE
.On [**2183-7-25**] he was transfused 1 unit of packed RBCs for ahemtocrit of 27.6. The Acute
Pain
DISEASE
Service continued to followthe patient for management of the epidural catheter. He wasadmitted to the CSRU for a day after surgery and was transferredto the floor on [**7-26**] after he was deemed to be stable. His chesttubes were placed to water seal and a chest radiograph showedvery slight increase in left pneomothorax.On [**7-27**] his anterior chest tube which was placedintraoperatively was removed without incident and his secondtube was put to bulb suction. A chest radiograph that was doneafter these changes were made showed no acute or concerningchanges in the left pneumothorax. His epidural catheter wasremoved and he was given oral
pain
DISEASE
medications.On [**7-28**] the patient's foley catheter was discontinued but thepatient failed to void 12 hours after removal. He wasadministered tamsulosin and his foley catheter was replaced. APA and lateral chest radiograph showed decreased left-sided
pneumothorax
DISEASE
and
interstitial edema
DISEASE
since the prior examinationwith small bilateral
pleural effusions
DISEASE
.On [**2183-7-29**] he underwent a video swallow study which revealed aleft vocal
cord paralysis
DISEASE
. The speech consultant recommended thefollowing:1. Diet of thin liquids and soft solids2. Swallow w/chin tucked to chest for all consistencies3. Pills whole in applesauce4. ENT consult to evaluate vocal cord mobility to r/o Left vocal cord paresis/paralysisAn otolaryngology consult was obtained for evaluation andtreatment for this condition the recommendation which were toobserve strict chin-tuck adherence and strict aspirationprecautions as the patient was thought to be at great aspirationriskAdmission Date: [**2187-3-26**] Discharge Date: [**2187-4-5**]Date of Birth: [**2105-12-3**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2972**]Chief Complaint:LLQ
Pain
DISEASE
and BRBPRMajor Surgical or Invasive Procedure:noneHistory of Present Illness:81 y/o M w/ h/o AAA s/p repair colon ca s/p sigmoidectomy
diverticulitis prostate cancer
DISEASE
and
non-small cell lung cancer
DISEASE
p/w 4 days of LLQ
pain
DISEASE
. Patient states that for the past fourdays he has had a band like
abdominal pain
DISEASE
across his lowerabdomen. On day of admission his home health aide noted brightred blood in his stools and so patient referred to the ED..In the ED initial vs were: VS 97.8 106 129/83 18 100%. Patientwith BRB on DRE and mild LLQ
pain
DISEASE
(intermittent). HR improvedwith 1L NS. CT A/P done in ED showed no acute abdominalpathology c/w patient's symptoms. Patient was observed and hadone further episode of BRBPR in the ED prior to ICU transfer.Repeat Hgb went from 10.9 on arrival to 8.2 (baseline Hgb[**11-19**])..On arrival to the ICU patient comfortable with stable VS. Onfurther questioning denies any recent f/c/n/v/ns/diarrhea/
constipation/weight gain
DISEASE
or weight loss/chest pain/syncope orother complaints.
Denies melena
DISEASE
.Review of systems:(Admission Date: [**2186-6-7**] Discharge Date: [**2186-6-11**]Date of Birth: [**2124-11-5**] Sex: MService: [**Hospital Ward Name **] ICUCHIEF COMPLAINT: Admission Date: [**2147-11-20**] Discharge Date: [**2147-11-24**]Date of Birth: [**2077-6-20**] Sex: MService: ORTHOPAEDICS
Allergies
DISEASE
:Sulfa (Sulfonamide Antibiotics)Attending:[**First Name3 (LF) 2988**]Chief Complaint:progressive bilateral leg weaknessMajor Surgical or Invasive Procedure:s/p L3-S1 lami/fusion with instrumentation [**2147-11-20**]History of Present Illness:70 y.o M p/w progressive lower back pains/leg weakness. Pthaving difficulty walking. Has transitioned from cane to walkerover past week. MRI noted for severe
L3-L5 spinal stenosis
DISEASE
.Past Medical History:Hand
tremors
DISEASE
Chronic neck pain
DISEASE
Diverticulosis s/p sigmoid
DISEASE
colectomyUrinary incontenencePSHx:ORIF right legORIF left forearmSigmoid colectomy
Cataract
DISEASE
Social History:married lives with wife - tobacco Admission Date: [**2136-2-24**] Discharge Date: [**2136-3-8**]Date of Birth: [**2083-3-11**] Sex: MService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2836**]Chief Complaint:1. Severe
abdominal pain
DISEASE
Major Surgical or Invasive Procedure:[**2136-2-24**]: Sigmoid colon resection and end colostomy.History of Present Illness:The patient is a 52 year old male who complains of ABD PAIN andunable to urinate. She was seen in the ED one week ago for leftlower quadrant
pain
DISEASE
diagnosed with
diverticulitis
DISEASE
and placedon Cipro Flagyl. That left lower quadrant pain has beengradually improving. However he urinated last nightnormally and then has been unable to urinate since then anddeveloped lower
abdominal pain
DISEASE
this morning. No
nausea vomiting
DISEASE
fevers
DISEASE
or
chills
DISEASE
.Past Medical History:PMH:
diverticulitis
DISEASE
PSH
DISEASE
: exploratory laparoscopy exploratory laparotomy (stabbing)Social History:The patient is a smoker and drinks occasional alcohol.Family History:Non contributoryPhysical Exam:On Admission:VS: T98.1 HR 90s BP 150/60 RR 18 Sats 100%RAGeneral:In moderate distressHEENT-anictericCV-RRRPulm-CTA b/lAbd-rigid rebound guarding diffuse abd
tenderness
DISEASE
. Wellhealed midline scar.Ext-no
edema
DISEASE
On Discharge:VS:General: NADHead/Neck: NC/AT suppleHeart: RRR no m/r/gLungs: Left CTA right - diminished on baseAbd: Distended firm tenderness around incision sites. Midlineincision: distal and proximal part with staplesAdmission Date: [**2138-8-25**] Discharge Date: [**2138-10-3**]Service: MEDICINE
Allergies
DISEASE
:Sulfonamides / Macrodantin / Codeine / Norvasc / Hydralazine /Heparin AgentsAttending:[**First Name3 (LF) 2195**]Chief Complaint:
anemia
DISEASE
and
acute renal failure
DISEASE
Major Surgical or Invasive Procedure:Renal biopsy [**9-1**]Placement of pheresis catheter [**9-3**]Plasma exchange [**9-3**] [**9-5**] [**9-8**]HemodialysisBronchoscopy [**2138-9-12**]Central line placement [**2138-9-12**]History of Present Illness:[**Age over 90 **] year-old female with
hypertension
DISEASE
admitted [**2138-8-25**] with acute
renal failure
DISEASE
secondary to hydralazine-induced
glomerulonephritis
DISEASE
(p-ANCA positive). Patient was initiallynonresponsive to steroids plasma exchange and was started onhemodialysis on [**2138-9-9**]. She received her second HD treatment on[**2138-9-11**]. During both treatments L IVF was removed. Both renaland rheumatology have followed patient to date. Cyclophosphamidewas considered but not started given concern for
toxicity
DISEASE
dueto age..Overnight patient developed oxygen requirement initiallyhypoxic to 90% on room air at rest 85% with ambulation. Oxygendelivery was increased progressively from 3L to 6L nasalcannula. She appeared volume overloaded on exam and CXR. She wasgiven Lasix 40mg IV x2 with minimal urine output. Nebulizerswere tried with minimal relief. Renal was called re: urgentdialysis which was not possible. Additionally given rapidprogression of
hypoxia
DISEASE
renal suspected etiology other than
volume overload
DISEASE
alone. Of note patient also with
hemoptysis
DISEASE
this morning on multiple occasions - largest approximately 1teaspoon bright red blood. Given progressive
hypoxia
DISEASE
andincreased work of breathing patient is transferred to [**Hospital Unit Name 153**] forfurther management..Hospital course also complicated by lower GI bleed
anemia
DISEASE
coagulopathy UTI
DISEASE
. On [**2138-9-10**] patient developed
LGIB
DISEASE
in contextof
constipation
DISEASE
and straining for bowel movement. GI wasconsulted. Based on recent colonoscopy transient diverticular
bleed
DISEASE
was suspected. Ischemic
colitis
DISEASE
was also considered givenunderlying
vasculitis
DISEASE
. Patient also with
chronic anemia
DISEASE
. She hasrequired 2 pRBC transfusions during this hospital course.Patient also with uncomplicated
UTI
DISEASE
treated with ciprofloxacinPO x3 days on admission..On arrival to [**Hospital Unit Name 153**] was with O2 saturation 100% on 100% O2
shovel mask. She complained of
shortness of breath fatigue
DISEASE
. Shewas urgently intubated given
respiratory distress
DISEASE
.Past Medical History:
Hepatitis B
DISEASE
secondary to transfusion ([**2078**])Hypercholestremia
Hypertension
DISEASE
Carotid stenosis
DISEASE
s/p endartarectomy
Arthritis
DISEASE
s/p right THR ([**2130**])
Gastritis
DISEASE
Prolapsed
bladder s/p bladder
DISEASE
suspension
Breast cyst
DISEASE
Social History:Lives in apartment above daughter's home. Well-supported byfamily. Active prior to admission - capable in all ADLs. Perdaughter no tobacco alcohol or illicit drug use. Formerlyworked at [**Company 3004**].Family History:unknownPhysical Exam:On admission [**2138-8-26**]:Pt is at baseline per daughter who is with ptPt is awake and responds appropriately. Able to tell me it is[**2138**] but unable to correctly tell me month or date or identifyname of president.97.8 197/77 78 14 99%RACV-RRRlungs - CTA bilatabd - soft nt nD no guardingext - no c/c/e.On admission to [**Hospital Unit Name 153**] (prior to intubation) [**2138-9-12**]:96.8 95 169/112 20 91% shovel mask 100%General: Labored respirations with use of accessory musclesHEENT: Sclera anicteric
dry blood
DISEASE
at mucous membranes and inmouth no site of active
bleeding
DISEASE
Neck: Supple JVP difficult to assess given accessory muscleuseLungs: Rhoncherous throughout with crackles to midlung fieldsbilaterallyAdmission Date: [**2148-4-22**] Discharge Date: [**2148-4-28**]Date of Birth: [**2090-4-5**] Sex: MService: ORTHOPAEDICS
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 3006**]Chief Complaint:left thumb amputationMajor Surgical or Invasive Procedure:[**2148-4-22**]: Dr. [**Last Name (STitle) **] - left thumb complete reimplantation atthe level of the proximal MP joint.History of Present Illness:58 year old right hand dominant man who accidently amputated hisleft thumb at the level of the distal metacarpal with a circularsaw when doing floor work at Admission Date: [**2135-2-8**] Discharge Date: [**2135-2-14**]Date of Birth: [**2052-1-30**] Sex: FService: MEDICINE
Allergies
DISEASE
:BactrimAttending:[**Doctor First Name 2080**]Chief Complaint:
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:thoracentesisHistory of Present Illness:Reason for MICU Admission:
hypoxia
DISEASE
respiratory distress.Primary Care Physician: [**Name10 (NameIs) 585**][**Name11 (NameIs) 586**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 589**].CC:
cough shortness
DISEASE
of breath.HPI: 83yo female Russian with history of
CLL
DISEASE
presenting with
respiratory distress
DISEASE
..Per patient she reports 6 days of productive
cough
DISEASE
andprogressive
dyspnea
DISEASE
. She reports associated
fevers
DISEASE
up to 100.2and sore throat. Two days prior to admission prescribed bactrimby her son who is a physician. [**Name10 (NameIs) **] [**Name11 (NameIs) 3010**] worsened and shepresented to her PCP [**Name Initial (PRE) 3011**]. There vital signs notable for O2 sat89%
RA
DISEASE
improved to 92% on 2L NC. CXR with right increasedeffusion and possible left sided infiltrate. She was referred toED for further eval..In the ED initial VS: 99.3 81 118/46 20 96%
NRB
DISEASE
. Labs notablefor WBC of 33.2 61% lymphocytesAdmission Date: [**2196-8-16**] Discharge Date: [**2196-8-18**]Date of Birth: [**2160-7-23**] Sex: FService: MEDICINE
Allergies
DISEASE
:Bactrim / Vioxx / Penicillins / Cellcept / Ceftriaxone /FerrlecitAttending:[**First Name3 (LF) 2817**]Chief Complaint:
Dyspnea
DISEASE
Major Surgical or Invasive Procedure:peritoneal dialysisHistory of Present Illness:Ms. [**Known lastname **] is a 36 year old female with a history of
SLE lupus
DISEASE
nephritis ESRD
DISEASE
on
PD
DISEASE
who presented to the ER with two days of
chest pain
DISEASE
and worsening
shortness of breath
DISEASE
. At home she hadbeen having
pain
DISEASE
. She had been having
pain
DISEASE
during her
PD
DISEASE
sessions at home and was having difficulty tolerating the
PD
DISEASE
sessions so she stopped doing her home
PD
DISEASE
sessions Sundayevening. Over the next few days she started having more
shortness of breath
DISEASE
was experiencing
chest heaviness orthopnea
DISEASE
and PND. Her
shortness of breath
DISEASE
worsened over and shepresented to the ER today for further evaluation. She denies any
cough nasal congestion
DISEASE
fever/chills night
sweats
DISEASE
n/v/d. Doeshave her baseline
abdominal pain
DISEASE
and has felt worseningAdmission Date: [**2198-4-22**] Discharge Date: [**2198-5-4**]Date of Birth: [**2160-7-23**] Sex: FService: MEDICINE
Allergies
DISEASE
:Bactrim / Vioxx / Penicillins / CellCept / Ceftriaxone /Ferrlecit / Sulfa (Sulfonamide Antibiotics)Attending:[**Last Name (NamePattern4) 290**]Chief Complaint:HEMOPTYSISMajor Surgical or Invasive Procedure:LEFT BRONCHIAL ARTERY EMBOLIZATION UNDER FLUOROSCOPYRIGHT INTERNAL JUGULAR LINE PLACEMENT REPOSITIONING ANDREMOVALIVC FILTER PLACEMENTINTUBATION AND MECHANICAL VENTILATIONHistory of Present Illness:37F with history of
lupus lupus nephritis
DISEASE
with
ESRD
DISEASE
onperitoneal dialysis on transplant list hx of PE/Antiphopholipidantibody on coumadin mitral regurg presents with 4-6 monthhistory of
cough
DISEASE
worse in the morning one week of trace bloodnow producing bright red blood over last couple days. Patientstates that the amount of blood she has been coughing has beenincreasing and is now almost hourly aprroximately 1 teaspoonbright red blood. Patient states that the
cough
DISEASE
producedprimarily yellow sputum until it turned to blood. Patient deniesany other symptoms such as
dizziness
DISEASE
or
lightheadedness
DISEASE
. Shedenies any changes in her BMs including consistency frequencyand color. Patient visited
PCP
DISEASE
on [**Name9 (PRE) 2974**] and a CXR wasnegative. Her was also noted to be subtherapeutic and she tookan extra day of 10 mg warfarin as instructed..Initial vitals in the ED were: 108 138/95 18 100%
RA
DISEASE
. Her HCTwas 29.6 her baseline is unclear but appears to be low 30s. INRwas 4.4. A CTA was done for concern of PE which showed: 1. Leftlower lobe consolidation with large amount of secretions/fluidwithin the left lower lobe segmental bronchi. 2. Centrilobularnodules and ground glass
opacities
DISEASE
throughout both lungscompatible with chronic collagen
vascular disease
DISEASE
progressedsince [**2191**]. Ground glass
opacities
DISEASE
could also represent
hemorrhage
DISEASE
. 3. Chronic left lower segmental pulmonary arterialPE unchanged since [**2191**]. No new acute PE detected to thesubsegmental levels. She was initially admitted to medicine butthen transferred to the ICU..On arrival to the MICU initial vitals were: 110 163/96 20 95%RA.She is breathing comfortably but complains of
pain
DISEASE
in her chest.Her EKG was reviewed which did not show changes from her prior.She also complains of a HA that she says she occasionallyrecieves toradol. She has had
emesis
DISEASE
in the ED that lookeddark/possibly coffee ground but currently denies
nausea
DISEASE
.Past Medical History:#
Lupus rash
DISEASE
#
Herpes Simplex I - [**12-2**] white lesions
DISEASE
on the tongue andbuccal mucosa# Axillary Adenopathy - [**10-2**] biopsied -Admission Date: [**2157-1-5**] Discharge Date: [**2157-1-11**]Date of Birth: [**2099-12-15**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1505**]Chief Complaint:
Shortness
DISEASE
of breath/Heart
failure
DISEASE
Major Surgical or Invasive Procedure:[**2157-1-7**] - Urgent mitral valve repair with triangular resectionof middle scallop of the posterior leaflet and annuloplasty witha 26-mm [**Company 1543**] 3-D annuloplasty ring.[**2157-1-5**] - Cardiac CatheterizationHistory of Present Illness:Delightful 57 year old female with a history of a myxomatousmitral valve and
mitral regurgitation
DISEASE
dating back to [**2126**]. Shehas been followed for moderate regurgitation and mild pulmonary
hypertension
DISEASE
with symptom observation and serialechocardiography. In [**2156-10-24**] she began to develop
shortness of breath
DISEASE
as well as
palpitations
DISEASE
. Her recentechocardiogram demonstrated a new partial flail of the posteriormitral leaflet (probably P2/P3 scallops) withwide-open MR and new severe
pulmonary hypertension
DISEASE
. Her leftatrial size had not changed in size thus suggesting the acutenature of her severe
mitral regurgitation
DISEASE
. Given these findingsshe has been referred for surgical management. She wasoriginally seen by Dr. [**Last Name (STitle) 3067**] in clinic on [**2156-12-30**] hoeverdeveloped worsening
shortness of breath and heart failure
DISEASE
neccessitating an earlier admission for surgery.Past Medical History:MR/MVP
HTN
DISEASE
Admission Date: [**2196-7-9**] Discharge Date: [**2196-7-28**]Date of Birth: [**2142-9-13**] Sex: FService: MEDICINE
Allergies
DISEASE
:Latex / ZanaflexAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:AMSMajor Surgical or Invasive Procedure:1. Intubation [**7-10**] by ICU team2. LP [**7-11**] by ICU team3. Tracheostomy [**7-20**] by Interventional Pulmonology (Dr. [**First Name8 (NamePattern2) **][**Last Name (NamePattern1) 3072**])4. PEG placement [**7-21**] by Gastroenterolgy (Dr. [**Last Name (STitle) **] [**Name (STitle) **])History of Present Illness:This is a 53 yo WF with a PMHx of advanced [**1-27**] progressive MSchronic indwelling foley h/o pe on coumadin who p/f personalcare home with AMS.The patient's last admission was [**2196-5-22**] who was admitted forAMS and acute on chronic lethargy. They dx her with toxic
metabolic encephalopathy
DISEASE
[**1-27**] to
UTI
DISEASE
and mrsa follicullitis (shehad a dermatomal
rash
DISEASE
). She was treated with vancomycin sheimproved was transitioned to orals bactrim and doxycycline andwas d/c..The following history was obtained from an LPN named [**Name (NI) **][**Name (NI) 3073**] at [**Telephone/Fax (1) 3074**]. She states that since the patientprior admission she never returned to her baseline. The patientseems to have a waxing and wanning mental status. She deniesseeing the patient have
twitching movements
DISEASE
or signs of
infection
DISEASE
such as recent
diarrhea fever
DISEASE
or
cough
DISEASE
. Temps at [**Hospital1 1501**]ranged from 99.2-99.4. The patient recently history is notablefor
non-compliance
DISEASE
both when she is oriented and when she isnot. She refuses UA evalaution and also refuses suprapubiccare. It is not clear when the last time her supr-pubic cathwas changed. Starting the day of admission the patient wasincoherent was unable to swallow her pills and was salivating.she was deemed usafe to be at her home and was sent to the EDand [**Hospital1 **]..The patient arrived to the ED and was intially minimallyresponsive. Per the ED reports she improved while there from aMS perspective. They did an I and D of the area around her SPcath and it was sent for culture which showed GPC in pairs andGPR. BC and Urine cultures were sent. The patient HCT showednothing acute and her CXR was wnl. The patient was givenlevofloxacin and sent to the floor.Past Medical History:1) Multiple sclerosis (advanced secondary progressive) -followed by Dr. [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **] in neurology clinic -diagnosed at age 23 -largely wheelchair bound needs assistance with transfer -chronic suprapubic catheter changed once monthly2) History of
pulmonary embolism
DISEASE
on coumadin3)
depression
DISEASE
4)
hyponatremia
DISEASE
5) h/o mrsa6) h/o c. diff
colitis
DISEASE
7) h/o intermitent
UTI
DISEASE
's in the pastSocial History:Non-smoker non-drinker. Lives at [**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] forLiving in [**Location (un) **]. Divorced.Family History:NCPhysical Exam:Admission Physical Exam:VS BP 140/94 P-64 R-18 SaO2-97
RA
DISEASE
General: Patient is able to answer yes and no questions but inmostly non verbal except [**12-27**] word statementsHEENT: CN 2-12 grossly intact mmm pupils equal and minimallyresponsive to lightEndo: no obvious thyroid nodulesCV: RRR no rmgLungs: CTAB no WRRAbdomen: non
TTP
DISEASE
active BS SP cath in place with minimal
erythema
DISEASE
and milkly residue on inside of tubeExtremities/Neuro:UE-some
rigidity
DISEASE
in bue 1Admission Date: [**2169-5-25**] Discharge Date: [**2169-5-31**]Date of Birth: [**2136-9-18**] Sex: FService:HISTORY OF PRESENT ILLNESS: The patient is a 32 year-oldwoman with a recurrent
demyelinating illness
DISEASE
brought to theEmergency Room by her parents on the recommendation of herneurologist for evaluation of behavior changes includingincreased sexual promiscuity increased spending andreport that she is compulsively wanting to have sexualactivity and unable to control it to the degree that she isplacing herself and her parents at risk. She has contact[**Name (NI) **]many men by computer and phone. Several nights prior toadmission her father heard noises in the middle of the nightand found a strange man in the patient's bedroom. The fathercalled the police and the police knew him to be a dangerousthe patient left the house unbeknown to the parents and waswaiting outside for a cab to take her to a motel where shehad arranged a liaison with the same man. The father statedhe had also escorted other strange men out of the house andis very worried about the patient and the families safety.She also has had increased spending and has had a progressivedecline in her ability to care for herself includingdecreased ambulation. The other stresses beside herdeclining physical abilities was that her fiance who was
bipolar
DISEASE
committed
suicide
DISEASE
by jumping in front of a train in[**2169-1-20**]. On [**2169-5-11**] she was seen by a neurologistand an MRI was ordered. The patient was then referred forevaluation for
psychiatric
DISEASE
admission for behavioral control.PAST PSYCHIATRIC HISTORY: Admission to [**Hospital1 190**] in [**2164-2-18**] for a
psychotic disorder
DISEASE
with
hallucinations
DISEASE
secondary to prescribed steroids. In [**2158**] shewas seen by a psychiatrist when her
neurological illness
DISEASE
wasfirst diagnosed and she started to exhibit disinhibitedbehavior and
impulsiveness
DISEASE
with late night phone calls. Herneuropsychologist is Dr. [**Last Name (STitle) 3085**].PAST MEDICAL HISTORY: She was diagnosed with a
demyelinating
DISEASE
illness in [**2158**] which has involved
frontal lobe dysfunction
DISEASE
and neurogenic bladder as well as difficulty with theambulation. She has
chronic sinusitis
DISEASE
. Her primary carephysician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3086**]. Her neurologist is Dr. [**Last Name (STitle) 3087**]and her consulting neurologist at [**Hospital1 190**] is Dr. [**Last Name (STitle) 3088**].ALLERGIES: Flu shots.MEDICATIONS ON ADMISSION: Baclofen 820 mg tablets q.d.Ditropan XL 20 mg q.d. Beconase nasal spray two times a dayferrous sulfate 325 mg a day Solu-Medrol q.m. intravenouslast dose [**2169-5-4**] next dose scheduled for [**2169-6-1**] and Celexa20 mg q.d.SUBSTANCE ABUSE HISTORY: The patient denies.SOCIAL HISTORY: Both the patient and her 28 year-old brotherwere adopted and live with their parents in [**Location (un) 38**][**State 350**]. She was six weeks old when she was adopted.She was an average student with no academic difficulties.Question of history of
sexual assault
DISEASE
in [**2159-7-21**]. Shegraduated from [**Last Name (Prefixes) 3089**] College where she studied earlychildhood development. She is single. Never married.FAMILY PSYCHIATRIC HISTORY: Not available.LABORATORY DATA ON ADMISSION: CBC and
SMA
DISEASE
were within normallimits. RPR was negative. HCG was negative. TSH was withinnormal limits. Tox screen was negative.MENTAL STATUS EXAMINATION ON ADMISSION: The patient waspleasant well groomed and appropriately dressed sitting on astretcher. Her attitude was cooperative. Her speech wasarticulate. Very matter of fact with little affect. Moodwas
depressed
DISEASE
. Affect minimally reactive. Thought form waslinear and coherent. She denied any preoccupations
obsessions
DISEASE
and
delusions
DISEASE
except for her thoughts about sex.She did not appear to have any
delusions
DISEASE
. She deniedsuicidal or
homicidal ideation
DISEASE
. Her insight and judgmentwere impaired. Her cognitive examination was abnormal in herinability to do serial sevens. She was able to do serialthrees. She remembered 2 out of 3 in five minutes.Calculations and fund of knowledge were within normal limits.HOSPITAL COURSE: The patient was admitted to [**Hospital1 **] Four.A trial of Depakote ER was begun to help with her impulsivebehaviors. Her family and her outpatient physicians werecontact[**Name (NI) **]. The patient was pleasant and involved in MILUactivities. She did have a fall on the unit with no acute
injuries
DISEASE
noted and fall precautions were put into place. Herfamily met with the inpatient team as well as Dr. [**Last Name (STitle) 3088**] whoreviewed her recent MRI and said that it showed worsening ofher
demyelinating disorder
DISEASE
which could be consistent withher current change in behavior. He would continue to followher. The patient had no further urges or attempts to engageanyone sexually and was in very good control on the unit.She did have another fall using her walker and began to useher wheel chair more frequently. She denies side effectsfrom the Depakote. On [**5-30**] she complained of an upset
stomach diarrhea
DISEASE
and a productive
cough
DISEASE
for three days withsome blood in her sputum. She denied any shortness ofbreath. Lungs were clear on examination. The patient had anextensive physical therapy consult and evaluation and furtherphysical therapy was recommended.Discharge planning proceeded with the patient agreeing to goto a brief rehab stay for continued physical therapy beforereturning home. On [**2169-5-31**] the patient was being assisted intransfer from bed to her wheel chair and had a sudden cardiacand
respiratory arrest
DISEASE
. CPR was initiated and she wastransferred to the Intensive Care Unit.In the MICU the patient was in
pulseless
DISEASE
electrical activity(PEA) and was felt to have suffered a massive pulmonary
embolism
DISEASE
. She was given thrombolysis with restoration of pulseand blood pressure while being maintained on vasopressors andmechanical ventilation. However despite maximum supportivemeasures
hypotension
DISEASE
became refractory and the patient diedwithin 24 hours of transfer to the ICU. The patient's family wasnotified of the events and was with the patient in her finalhours. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**] M.D.[**MD Number(1) 3091**]Dictated By:[**Last Name (NamePattern1) 3092**]MEDQUIST36D: [**2169-7-24**] 17:18T: [**2169-8-1**] 07:09JOB#: [**Job Number 3093**]Admission Date: [**2141-7-9**] Discharge Date: [**2141-7-13**]Date of Birth: [**2095-12-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2297**]Chief Complaint:
overdose
DISEASE
Major Surgical or Invasive Procedure:IntubationHistory of Present Illness:Mr. [**Known lastname 2445**] is a 45 year old man who presented to the [**Hospital1 18**] via[**Location (un) 86**] EMS. Pt was found by EMS at his home at 10:21pm [**2141-7-8**].The patient was supine pt was noted to by awake and alert BP120/88 pulse 72. He was noted to have overdosed taking Admission Date: [**2120-11-15**] Discharge Date: [**2120-11-16**]Date of Birth: [**2071-12-22**] Sex: MService: MEDICINE
Allergies
DISEASE
:Demerol / Zidovudine / Dilaudid / LevaquinAttending:[**First Name3 (LF) 2297**]Chief Complaint:Found down in apartment by Social WorkerMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:48 y/o M with PMH of HIV/AIDS last CD4 13 [**8-17**] and VL 51000[**5-18**]
candidal esophagitis peripheral neuropathy
DISEASE
who presentsafter being found down in his apartment. He was brought in myEMS and intubated in ED due to combativeness and altered mentalstatus. Further history unable to be obtained from patient orHCP who was unable to be reached..In the ED VS were rectal T [**Age over 90 **] F BP 104/palp HR 60 RR 16. Hewas given etomidate and rocuronium pre-intubation and placed onpropofol gtt. He was given 2L NS and 2L LR as well as 1gm IVvancomycin and 2gm ceftriaxone. Toxicology was consulted andrecommended charcoal 50gm. he was placed on a bear hugger andrectal temp came up to 93. He was transferred to the ICU forfurther care. On arrival to ICU VS were stable. He was placedunder warming blanket and arterial line was placed.Past Medical History:1. HIVAdmission Date: [**2166-10-4**] Discharge Date: [**2166-10-7**]Date of Birth: [**2094-5-31**] Sex: MCHIEF COMPLAINT:
Sepsis
DISEASE
and
renal failure
DISEASE
.HISTORY OF PRESENT ILLNESS: The patient is a 72-year-oldgentleman with an extensive past medical history includingcomplicated by persistent
respiratory failure
DISEASE
(on chronictracheostomy)
hypertension
DISEASE
restrictive
lung disease
DISEASE
cardiomyopathy
DISEASE
and
cirrhosis
DISEASE
who presented with worseningrespiratory status and episodes of
hypotension
DISEASE
.The patient lives at [**Hospital3 672**] HospitalAdmission Date: [**2129-6-12**] Discharge Date: [**2129-6-14**]Date of Birth: [**2050-1-17**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2704**]Chief Complaint:Planned Left internal carotid angio/stentMajor Surgical or Invasive Procedure:Catheterization with left internal carotid stent placement.History of Present Illness:Pt is a 79 yo male CAD s/p CABG
PVD R Coronary artery
DISEASE
stenting
systolic CHF
DISEASE
(EF 45%)
CRF
DISEASE
(creat 1.9) and
HTN
DISEASE
who isnow s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] stenting. In [**Month (only) 958**] and [**Name (NI) **] pt had episodes x1 ofLOC. In [**Month (only) 958**] his wife walked into the room to find him
hunched
DISEASE
over in his chair with Admission Date: [**2140-11-5**] Discharge Date: [**2140-11-18**]Date of Birth: [**2101-3-21**] Sex: FService:HISTORY OF PRESENT ILLNESS: The patient is a 39-year-oldfemale with
end-stage renal disease
DISEASE
secondary to
diabetes
DISEASE
.She also has a history of
hypertension
DISEASE
peripheral vasculardisease and
hypothyroidism
DISEASE
who presented with
chest pain
DISEASE
.The patient felt chest pressure while walking and hadassociated
shortness of breath and emesis
DISEASE
. She did haverelief with rest. On admission she did also note that herblood sugars were running higher than normal. She did have astress test five years ago as a possibility for transplantoption which was normal.In the Emergency Department the patient was given aspirinceftriaxone Lopressor and was
chest pain
DISEASE
free.PAST MEDICAL HISTORY: (Her past medical history includes)1. Type 1
diabetes
DISEASE
with associated
retinopathy
DISEASE
and
neuropathy
DISEASE
.2.
Hypertension
DISEASE
.3. Peripheral
vascular disease
DISEASE
.4. End-stage
renal disease
DISEASE
(hemodialysis dependent). Herhemodialysis schedule is on Monday Wednesday and Friday.5. History of
hypothyroidism
DISEASE
.6. Status post percutaneous transluminal coronaryangioplasty of the bilateral lower extremities.7. Status post amputation of her right foot.SOCIAL HISTORY: The patient moved here from [**State 108**] andlives with her mother in [**Name (NI) 8**]. She does not smoke. Shedoes not drink alcohol. She does not use intravenous drugs.She does ambulate with a cane.ALLERGIES: The patient has
allergies
DISEASE
to CLINDAMYCIN (whichgives her
diarrhea
DISEASE
) LEVAQUIN (which gives hergastrointestinal upset) and ZEMPLAR (which gives her a
rash
DISEASE
).MEDICATIONS ON ADMISSION: (Her medications on admissionincluded)1. Plavix 75 mg by mouth once per day.2. Atenolol 25 mg by mouth once per day.3. NPH insulin 26 units subcutaneously in the morning with16 units subcutaneously regularAdmission Date: [**2145-3-11**] Discharge Date: [**2145-3-17**]Date of Birth: [**2101-3-21**] Sex: FService: MEDICINE
Allergies
DISEASE
:Clindamycin / Zemplar / Levofloxacin / Trazodone / DoxycyclineAttending:[**First Name3 (LF) 348**]Chief Complaint:
hypotension
DISEASE
line
infection
DISEASE
Major Surgical or Invasive Procedure:IR placement on tunelled
HD
DISEASE
line on [**3-16**]History of Present Illness:43F with
ESRD
DISEASE
on HD
DM1
DISEASE
CAD s/p CABG h/o poor access withfailed
AV fistulas
DISEASE
presenting with pus coming from
HD
DISEASE
line.Systolic BPs to 80s patient appeared sick and was not mentatingwell. Lactate was 3.0. Therefore peripheral dopamine started(patient did not want central line). She did not have arterialline. On arrival on the floor
hypotensive
DISEASE
to sbp of 84 buttalkative mentating. says baseline BP is in 110s. Given thatpatient does not have dialysis access she was not given IVF.Pressure has now improved to mid-90s systolic. Of note patient admitted to [**Hospital1 18**] [**12/2144**] for tunelled line
infection
DISEASE
. the line was removed and replaced at that time. ATTE did not show evidence of
endocarditis
DISEASE
at that time. A TEEwas attempted but not completed because of patient intolerance. She denies known exposure to line site to cause
infection
DISEASE
.She wonders about sterility of dressings at her outpatient
HD
DISEASE
center. Upon arrival at the [**Hospital1 18**] ED patient was
febrile
DISEASE
to 101.5later peaking at 102.6. Central line considered but patientrefused.Past Medical History:1. CAD s/p CABG x 3 in [**10-27**]2.
DM1
DISEASE
since age of 63.
ESRD
DISEASE
on
HD
DISEASE
being worked up for transplant4. h/o MRSA rt stump
infection
DISEASE
5.
anemia
DISEASE
6.
PVD
DISEASE
s/p
TMA
DISEASE
7. h/o epistasis from right nostril8. Bell's
Palsy
DISEASE
(right side s/p valtrex x 7 days last [**1-2**])9. AAA repair in '[**39**]10. h/o previous tunelled line
infection
DISEASE
.Social History:No tobacco alcohol or illicit drug useFamily History:Mother: [**Name (NI) 2481**] disease and CADFather: deceased from prostate CASiblings are all alive and wellPhysical Exam:Exam on transfer to floorVitals: T 94.5
84/doppler
DISEASE
67 16 98%RAGeneral: well-appearingNeck: no JVDCV: RRR nl S1 S2 no murmursLungs: Crackles at bases bilaterallyAbd: Soft NT ND Admission Date: [**2145-5-17**] Discharge Date: [**2145-5-24**]Date of Birth: [**2101-3-21**] Sex: FService: MEDICINE
Allergies
DISEASE
:Clindamycin / Zemplar / Levofloxacin / Trazodone / Doxycycline /HaldolAttending:[**First Name3 (LF) 603**]Chief Complaint:Hypoxia altered mental statusMajor Surgical or Invasive Procedure:HD translumen cathHistory of Present Illness:Ms. [**Known lastname 3123**] is a 44 yoF with
DM1 ESRD
DISEASE
[**12-26**]
diabetic nephropathy
DISEASE
on
HD
DISEASE
hx MRSA HD line
infections
DISEASE
hx of CABG and AAA repair whopresented to the ED on [**2145-5-17**] with multiple vague complaints.Patient was reportedly hypoxic confused and
febrile
DISEASE
at hernursing home. She is anuric so no urine sample was sent. CXRwas clear. Given her h/o AAA she underwent a CT torso with IVcontrast which demonstrated no evidence of PE aorticdissection or AAA. No parenchymal lung process other thandependent
atelectasis
DISEASE
and a small right
pleural effusion
DISEASE
. Shewas
hypotensive
DISEASE
in the ED but intially responded to fluids. BCxdrawn prior to vancomycin 1gm IV.Past Medical History:1. CAD s/p CABG x 3 in [**10-27**]2.
CHF
DISEASE
- EF 20-25% Severe regional and moderate global LV
systolic dysfunction
DISEASE
.3. Mild
mitral and tricuspid regurgitation
DISEASE
.4.
DM1
DISEASE
since age of 65.
ESRD
DISEASE
on
HD
DISEASE
. Failed R and L AVG now has tunneled HD catheterLIJ most recently replaced [**3-2**]. Changed from RIJ [**10-31**]. MRSA
infection
DISEASE
[**1-1**] catheter changed (clot in R IJ) Rx vanc til[**2145-1-23**]. Then another line change [**3-2**] for infected tunneledline.6. h/o MRSA rt stump
infection
DISEASE
7.
anemia
DISEASE
8.
PVD
DISEASE
s/p
TMA
DISEASE
9. h/o epistasis from right nostril10. Bell's
Palsy
DISEASE
(right side s/p valtrex x 7 days last [**1-2**])11. AAA repair in '[**39**]12. h/o previous tunelled line
infection
DISEASE
.Social History:No tobacco alcohol or illicit drug useFamily History:Mother: [**Name (NI) 2481**] disease and CADFather: deceased from prostate CASiblings are all alive and wellPhysical Exam:Physical Exam:Vitals: T 98.0 BP: 109/68 HR: 97 RR: 18 SaO2: 99% 2L NCGeneral: pleasant chronically ill appearing A&Ox3Neck: Supple. No LAD. JVP Admission Date: [**2113-11-8**] Discharge Date: [**2113-11-22**]Date of Birth: [**2029-9-9**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 922**]Chief Complaint:increasing
angina
DISEASE
Major Surgical or Invasive Procedure:[**2113-11-9**] CABG x5 (LIMA to LAD SVG to RCA seq. to PDA SVG toOM SVG to DIAG)[**2113-11-8**] cardiac cath with IABPHistory of Present Illness:84 yo w/several month h/o
exertional
DISEASE
shoulder discomfort which is relieved w/NTG. He has had 3 dayh/oworsening
shortness of breath and shoulder pain
DISEASE
. On admissionherecieved nitroglycerin and his
chest pain
DISEASE
was relieved. On EKGhe was found to have STD laterally andapically as well as QW anteriorly as well as positive troponinwith an acute MI.This pm on the floor the patient developed worsening
confusion
DISEASE
and
hypotension
DISEASE
. He was taken to the cath lab where he wasfoundto have severe left main disease and developed
hypotension
DISEASE
withinjection of the coronary arteries. He required an intra aorticballoon pump for hemodynamic stabilization and decision was madeto take him emergently to the operating room.Past Medical History:
Coronary artery disease
DISEASE
type 2 diabetes
DISEASE
peripheral arterial disease
DISEASE
hypertension
DISEASE
hyperlipidemia
DISEASE
peptic ulcer disease
DISEASE
severe
GI bleed
DISEASE
[**2106**]
trigeminal neuralgia
DISEASE
Left lumbar radiculopathy
DISEASE
secondary to degenerative
disc disease
DISEASE
Past Surgical Historys/p bilateral CEAs/p appendectomys/p bilat
cataract
DISEASE
surgerySocial History:The patient lives alone widowed three children. He is nowretired former teacher. He denies alcohol drug. Tobacco use 30years 1ppd. quit 30 years ago.Family History:from OMR: father
MI
DISEASE
at 57. MI in several uncles. Motherreportedly died from
peritonitis
DISEASE
.Physical Exam:Admission Physical ExamPulse:86 Resp: O2 sat:B/P Right: 120/85 Left:Height: 65Admission Date: [**2178-4-25**] Discharge Date: [**2178-4-30**]Date of Birth: [**2138-6-3**] Sex: MService: MEDICINE
Allergies
DISEASE
:Penicillins / BactrimAttending:[**First Name3 (LF) 2745**]Chief Complaint:etoh withdrawl
rhabdomyolysis
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Patient is a 39 yo male with pmhx HIV (unknown cd4 viralload)on HAART brought in by police after being found down behinda dumpster. No records available in computer and ED thinks thatpt gets most of his care at [**Hospital1 2177**]. Neurology was initiallyconsulted for altered mental status which they attributed totoxic/metabolic issues etoh intoxication
UTI
DISEASE
but recommendedthat if he continued to have altered sensorium and not clearappropriately to consider LP for CNS
infection
DISEASE
and MRI to r/otoxo PML etc. Head CT was negative. Serum etoh was 229 and hehad an anion gap of 39 on presentation to the ED. He was goingto be admitted to the floor but the floor team asked foradditional studies to work up his anion gap and he was found tohave a lactate of 8. He was given broad spectrum abx includingvancomycin levaquin and ceftriaxone. Toxicology was consultedand recommended checking an osm gap which was 79 by mycalculation. Toxicology recommended giving IVF and if thelactate and osmolar gap improved with fluid then it wasunlikely to be due to ethylene glycol or methanol intoxication.After 5 liters of IV NS lactate decreased from 8--Admission Date: [**2143-11-17**] Discharge Date: [**2143-11-23**]Date of Birth: [**2096-10-21**] Sex: MService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1384**]Chief Complaint:47M admitted for liver transplantation. Most recenthospitalization for R VATS biopsy of a lung nodule concerningformetastatic
HCC
DISEASE
.ROS: denies
fevers chills nausea vomiting diarrhea dysuria
DISEASE
hematuria
DISEASE
URI symptoms cough shortness of breath or anyother
pain
DISEASE
or discomfortMajor Surgical or Invasive Procedure:Orthotopic liver transplantation done on [**2143-11-19**]Past Medical History:HBV
Heptocellular Carcinoma
DISEASE
s/p
RFA
DISEASE
Hamartoma
DISEASE
.
Hypertension
DISEASE
.Social History:Cantonese and has a high school education. He is married andhastwo children ages 15 and 17. He is a restaurant cook.He has no history of alcohol use. He smoked one pack ofcigarettes per day in the past but quit 10 years ago. He has nohistory of IV drug use marijuanause blood transfusions tattoos or piercing.Family History:His family medical history is significant for his mother who isalive and healthy. His father died of unknown causes.Physical Exam:98.4 111 135/98 18 97%
RA
DISEASE
Gen: NADHEENT: EOMI not
jaundiced
DISEASE
mucous membranes moist no cervical
lymphadenopathy
DISEASE
no supraclavicular
lymphadenopathy
DISEASE
no JVDChest: CTAB RRR no M/R/GAbdomen: soft non-tender non-distendedExtremities: no
edema
DISEASE
2Admission Date: [**2188-2-8**] Discharge Date: [**2188-3-4**]Service: MEDICINE
Allergies
DISEASE
:HydralazineAttending:[**First Name3 (LF) 3151**]Chief Complaint:Admission Date: [**2182-2-18**] Discharge Date: [**2182-2-28**]Date of Birth: Sex: FService:HISTORY OF PRESENT ILLNESS: The patient is a 70-year-oldfemale with a complex medical history who was admitted aftera
cardiac arrest
DISEASE
on [**2182-2-18**]. She was initially taken to theCCU thought to be in
congestive heart failure
DISEASE
. Subsequentlydeveloped
sepsis
DISEASE
acute ARDS respiratory-cardiopulmonaryfailure. On [**2182-2-28**] at 3:15 p.m. the patient waspronounced dead. Family was at bedside.Date of
death
DISEASE
[**2182-2-28**]. Time of
death
DISEASE
3:15 p.m. [**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern4) 2462**] [**MD Number(1) 2463**]Dictated By:[**Last Name (NamePattern4) 2464**]MEDQUIST36D: [**2182-5-20**] 16:12:18T: [**2182-5-21**] 01:55:14Job#: [**Job Number 2465**]Admission Date: [**2108-5-16**] Discharge Date: [**2108-6-4**]Date of Birth: [**2033-4-24**] Sex: FService: NeurosurgeryHISTORY OF PRESENT ILLNESS: The patient is a 75-year-oldwoman with a sudden collapse. The daughter immediatelycalled EMS. The patient was taken to an outside hospital andwas found to have a
GCS
DISEASE
of 5. She was intubated sedated andtransferred to [**Hospital1 69**] forfurther evaluation.MEDICATIONS ON ADMISSION: 1. Lisinopril 40 mg q. day. 2.Atenolol 12.5 q. day. 3. Celebrex 20 mg q. day. 4. Lasix 20mg q. day.PAST MEDICAL HISTORY:
Hypertension
DISEASE
.HOSPITAL COURSE: The patient's blood pressure at the outsidehospital was in the 190s. She was given Mannitol and bloodpressure was stable on transport. The patient partiallyopened her left eye to sternal rub. Pupils were 2 down to 1mm and brisk. She had positive corneals positive gag. Shelocalized in the left upper extremity to
pain
DISEASE
flexor
posturing
DISEASE
in the right upper extremity withdrew bilaterallower extremity left greater than right.Head CT showed a large
intraventricular hemorrhage
DISEASE
withcasting of the left lateral ventricle blood surrounding the
edema
DISEASE
causing shift of midline structures. She was takenemergently to the operating room for a left frontalcraniotomy for evacuation of the
hematoma
DISEASE
.Upon arrival to the
trauma
DISEASE
surgical intensive care unitpostoperatively the patient was sedated on propofol. She waslightened for examination. Her pupils were 2 mm and brisk.Her right corneal was impaired her left was intact. Gag wasabsent. Cough was intact. She did not respond to verbalstimuli withdrew bilateral lower extremities to painfulstimuliAdmission Date: [**2125-2-1**] Discharge Date: [**2125-2-19**]Service: MEDICINE
Allergies
DISEASE
:UltramAttending:[**First Name3 (LF) 2160**]Chief Complaint:
Hematuria cough abdominal pain
DISEASE
Major Surgical or Invasive Procedure:IVC filter placementHistory of Present Illness:85 F h/o stage 0
CLL
DISEASE
not requring tx previously presents to EDfor persistent
cough/abdominal pain
DISEASE
and
hematuria
DISEASE
..Pt notes about 2 months of increasing
fatigue
DISEASE
nightsweatsdecreased appetite and increasing left side
abdominal pain
DISEASE
(intermittent no relation to food BM sharp no
diarrhea
DISEASE
constipation melena
DISEASE
). She was seen by PCP [**2125-1-9**] felt to haveviral URI symptoms persisted and seen again [**2125-1-23**] withpersistent
cough
DISEASE
(intermittently productive yellow-white)single episode of
hematuria
DISEASE
(clear red not clot) and LLQ
abdominal pain
DISEASE
treated with azithromycin and abdominal USobtained which revealed new
splenomegaly
DISEASE
with new 1.5-cmechogenic area.On [**1-31**] pt noted recurrent episode of Admission Date: [**2145-9-20**] Discharge Date: [**2145-9-26**]Date of Birth: [**2093-1-29**] Sex: MService: Thoracic surgeryHISTORY OF PRESENT ILLNESS: Patient is a 52 year-old malewith history of
atrial fibrillation
DISEASE
who had experiencedpresumed onset of
chest pain
DISEASE
over the past few weeks. He didnot complain of any
chest pain
DISEASE
at rest. He has usedsublingual nitroglycerin the past. Patient was admitted toan outside hospital with the increased symptoms. Heunderwent stress test in [**2145-9-1**] which showed diffuseST
depression
DISEASE
thus he was transferred to the [**Hospital1 346**] for further evaluation and possiblecoronary artery revascularization.PAST MEDICAL HISTORY: Is significant for
hypertension
DISEASE
aformer smoker and
depression
DISEASE
. He has no known drug
allergies
DISEASE
. His medications at home include LopressorCoumadin for paroxysmal
atrial fibrillation
DISEASE
aspirin.PERTINENT LABORATORY DATA: His hematocrit was 38.6BUN/creatinine 11/1.0.HOSPITAL COURSE: Patient was admitted to the cardiologyservice and he underwent cardiac catheterization on [**2145-9-20**]which showed an ejection fraction of approximately 67 percentand 90 percent discrete
mid-LAD stenosis
DISEASE
with 60 percentproximal circumflex and 60 percent OM2 stenosis. Patient wasreferred to Dr. [**Last Name (STitle) 1537**] for revascularization. He underwent offpump coronary artery bypass graft times two on [**2145-9-22**]. He received a LIMA graft to the LAD and saphenous veingraft to the LAD and saphenous vein graft to the OM1. Hetolerated the procedure well without any complications andwas transferred to the Cardiac Intensive Care Unit in stablecondition. He was extubated postoperatively and wastransferred to the floor on postoperative day one. Physicaltherapy was consulted and patient was noted to be doingextremely well with ambulation. On postoperative day onepatient did experience
atrial fibrillation
DISEASE
which wascontrolled with intravenous Lopressor Amiodarone anddiltiazem drip. He was noted to convert to a normal sinusrhythm on postoperative day two. The diltiazem drip wasdiscontinued and Amiodarone was converted to oral dose. Onpostoperative day three he again was ambulating extremelywell. He was noted to clear level 5 with the physicaltherapist and was able to [**Last Name (un) 3180**] and down stairs. Heremained afebrile with stable vital signs. His pulse was 71blood pressure was 105/61 and he was maintained on Lopressor75 mcg p.o. b.i.d. and Cardizem CD 80 mg q.d. and Amiodarone.Patient is currently postoperative day four and is beingdischarged home in stable condition.DISCHARGE DIAGNOSIS:
Coronary artery disease
DISEASE
status post off pump coronary arterybypass graft times two.DISCHARGE MEDICATIONS: Include Lopressor 75 mg p.o. b.i.d.Lasix 20 mg p.o. b.i.d. times three days KayCiel 20 mEq p.o.b.i.d. times three days aspirin 81 mg p.o. q.d. Plavix 75mg. p.o. q.d. Amiodarone taper 400 mg p.o. t.i.d. times fivedays then b.i.d. times seven days then 200 mg p.o. q.d.Cardizem CD 180 mg p.o. q.d. Percocet 1 to 2 pills q 4 to 6hours and Colace 100 mg p.o. b.i.d.DISCHARGE MEDICATIONS: 1) Patient is to continue taking allhis medications. 2) He should follow up with Dr. [**Last Name (STitle) 1537**] andhis primary care physician in approximately three week. 3)Regarding patient's Coumadin dose for paroxysmal atrial
fibrillation
DISEASE
patient is currently managed with Amiodarone.He will be treated with Plavix for the next three to sixmonths and after Plavix is discontinued patient should resumehis Coumadin. Patient is not recommended to be both onPlavix and Coumadin as hemostasis will be completelydisrupted. The patient should follow up closely with hisprimary care physician and his cardiologist. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**] M.D. [**MD Number(1) 1540**]Dictated By:[**Name8 (MD) 3181**]MEDQUIST36D: [**2145-9-26**] 11:17T: [**2145-9-26**] 12:23JOB#: [**Job Number 3182**]Admission Date: [**2166-8-25**] Discharge Date: [**2166-8-27**]Service: [**Hospital Unit Name 196**]Allergies:PrednisoneAttending:[**First Name3 (LF) 2704**]Chief Complaint:
amaurosis fugax
DISEASE
and
syncope
DISEASE
Major Surgical or Invasive Procedure:L Internal carotid artery stent placement.History of Present Illness:82 yo Male with symptomatic [**Doctor First Name 3098**] stenosis admitted to CCU aftercarotid stent placement. Pt has severe
vascular disease
DISEASE
- 90%[**Doctor First Name 3098**] stenosis 30-60% [**Country **] stenosis CAD - NQWMI in [**2-11**] (found2VD - 70% ostial RCA TO LCx distally with collateral flow). Ptalso has
PVD
DISEASE
and Admission Date: [**2166-12-22**] Discharge Date: [**2166-12-27**]Service:Transferred to the vascular service under the care of Dr.[**Last Name (STitle) **] on [**2166-12-23**].CHIEF COMPLAINT: Claudication.HISTORY OF PRESENT ILLNESS: This is an 82-year-old gentlemanof Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3185**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who has a historyof
peripheral vascular disease
DISEASE
and
renal artery stenosis
DISEASE
whowas referred for intervention for his peripheral vasculardisease.HISTORY OF PRESENT ILLNESS: The patient had a cardiaccatheterization on [**2164-2-28**] for progressive
dyspnea
DISEASE
.The findings at that time demonstrated the left main wasnormal. The anterior descending proximally was scatteredmild limb irregularities. The circumflex also had mildirregularities proximally and was totally occluded distallywith bridging collaterals and septal collateral flow to thedistal vessel and left PDA. The right coronary was non-dominant with an ostial lesion of 70%. The patient also wasknown to have
carotid disease
DISEASE
with symptomatic left internal
carotid artery stenosis
DISEASE
. He underwent a precise stentplacement on [**2166-8-25**]. He was also found to have an80% focal lesion of the left renal artery and severe rightcommon
femoral artery disease
DISEASE
. On [**11-7**] he had aperipheral arteriogram for progressive claudication. His wasfound to have bilateral
iliac disease
DISEASE
with severe rightcommon
femoral disease
DISEASE
and occluded left common femoralartery and bilateral SFA occlusions. Attempts to cross theleft common
femoral stenosis
DISEASE
into the PFA failed.An MRI was done on [**2166-11-21**] showed symmetrical
peripheral vascular disease
DISEASE
with longstanding segmentalocclusions at both superficial femoral arteries and posteriortibial arteries. A 3.4 cm occlusion of the left commonfemoral artery. The patient was referred for renalarteriogram and intervention. The patient has left greaterthan
right claudication
DISEASE
at walking at 100 feet.PAST MEDICAL HISTORY: Prednisone causes
agitation
DISEASE
.MEDICATIONS ON ADMISSION: Included Lasix 20 mg daily Imdur30 mg daily Proscar 5 mg daily glyburide 2.5 mg dailycaptopril 25 mg b.i.d. Plavix 75 mg daily aspirin 325 mgdaily simvastatin 10 mg daily amitriptyline 10 mg dailySerevent Diskus 50 mcg b.i.d. Albuterol and Atrovent inhalersp.r.n. Flovent 220 mcg b.i.d. albuterol nebs 0.83% andipratropium 0.02% nebs q.i.d.MEDICAL HISTORY: He has a history of
syncope
DISEASE
known
peripheral vascular disease
DISEASE
known
carotid disease
DISEASE
with ahistory of
amaurosis fugax
DISEASE
history of
glaucoma
DISEASE
history of
COPD
DISEASE
O2 dependent. He requires 1.5 liters with activitiesand 3 liters at night. He is a non-insulin
type 2 diabetic
DISEASE
.He has common
bile duct stones
DISEASE
. He has a benign nodule whichwas removed from his lung in [**2159**]. Other surgeries includebilateral
cataract
DISEASE
surgery in [**2161**] appendectomy at the ageof 52.SOCIAL HISTORY: Is married for 55 years and is a retiredcarpenter.His family history is positive for
pulmonary embolus
DISEASE
.HOSPITAL COURSE: The patient was admitted to the cardiacholding area. He underwent an attempted catheterization byDr. [**First Name (STitle) **] on [**2166-12-22**]. They were not able toangioplasty the left common femoral and arteriogram andselective renal angiography were done. Vascular service wasconsulted that day. His pulse exam was biphasic femoralspopliteals bilaterally with monophasic DP and PT on the leftand absent DP on the right with a monophasic PT on the right.The patient underwent on [**2166-12-24**] a left commonfemoral artery endarterectomy and patch angioplasty. Hetolerated the procedure well. He had a monophasic DP and PTat the end of the procedure. He was transferred to the PACUin stable condition. He then was transferred to the VICU forcontinued monitoring and care.Postoperative day #1 the patient will had no overnightevents. His pulse exam remained unchanged. His IV fluidswere
hep-locked
DISEASE
. His diet was advanced as tolerated andambulation was begun. The patient was evaluated by physicaltherapy who felt that he would be safe for discharge homewith wife and recommended home safety evaluation.The patient was discharged to home on [**2166-12-27**]. Hisfoot was warm. His Foley was discontinued prior to dischargeand he had no difficulty with voiding. He should follow upwith Dr. [**Last Name (STitle) **] in two week's time. Follow up with Dr.[**First Name (STitle) **] in 1 month's time. He should continue hispreadmission medications.DISCHARGE DIAGNOSIS:1. Bilateral
femoral occlusive disease
DISEASE
attempted angioplasty failed status post left common femoral endarterectomy with patch angioplasty.2. History of
chronic obstructive pulmonary disease
DISEASE
O2 dependent stable.3. Type 2
diabetes
DISEASE
on oral agents controlled.4.
Hypertension
DISEASE
controlled.5.
Hyperlipidemia
DISEASE
treated.6.
Renal artery stenosis
DISEASE
.7.
Carotid artery disease
DISEASE
status post stent placement of the left internal carotid artery.8. History of
glaucoma
DISEASE
.9. History of the bile duct stones.10. Status post bilateral
cataract
DISEASE
surgeries.11. Status post cholecystectomy.12. Status post benign lung nodule excision in [**2159**].13. Status post appendectomy at age 52. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 3186**]Dictated By:[**Last Name (NamePattern1) 2382**]MEDQUIST36D: [**2167-4-9**] 12:10:48T: [**2167-4-11**] 09:16:20Job#: [**Job Number 3187**]Admission Date: [**2179-8-5**] Discharge Date: [**2179-8-30**]Date of Birth: [**2120-1-7**] Sex: FService: ORTHOPAEDICS
Allergies
DISEASE
:Aspirin / NsaidsAttending:[**First Name3 (LF) 3190**]Chief Complaint:Bilateral
pneumonia
DISEASE
Major Surgical or Invasive Procedure:Bilateral Chest tubes placed by VATSIntubation and ventilationHistory of Present Illness:59F with past medical history significant for chronic steroiduse due to
lichen planus degenerative disk disease
DISEASE
with spinalstenosis on chronic narcotics
hypertension diabetes
DISEASE
irondeficiency
anemia
DISEASE
presents with severe
RUQ pain
DISEASE
that waspleuritic radiating to right shoulder at [**Hospital3 **]. Giventotal of 10 mg dilaudid between 3-6pm for
pain
DISEASE
subsequentlydeveloped
desaturation
DISEASE
to 85% on room air-Admission Date: [**2179-8-5**] Discharge Date: [**2179-8-29**]Date of Birth: [**2120-1-7**] Sex: FService: ORTHOThis 59-year-old female was transferred from Medicine Serviceafter acute treatment for
empyema
DISEASE
. She was medicallycontrolled with Vancomycin and completed a course for heracute
pneumonia
DISEASE
.It was noted that she developed
spondylitis
DISEASE
involving the L4-5 interspace a level where a previous posterior spinal fusionwithout instrumentation had been performed.PROCEDURE: An anterior retroperitoneal left flank approachwas performed with debridement of the L4-5 spondylitic disc spaceand interbody fusion with iliac crest bone graft autogenous andallograft bone.HOSPITAL COURSE: She was transferred from the Medicine serviceafter completing a course for acute
pneumonia
DISEASE
. Her new
pain
DISEASE
due to the
spondylitis
DISEASE
was treated with the above mentionedsurgery.Postoperatively her incision healed and her preoperative
pain
DISEASE
from the spinal condition the
infection
DISEASE
resolved. Shehad expected
incisional pain
DISEASE
and the
Chronic Pain
DISEASE
Serviceassisted in managing her
pain
DISEASE
issues.She mobilized to ambulation with a TLSO
brace
DISEASE
and
oral pain
DISEASE
medication alone.She resumed normal bowel and bladder function.She was discharged to rehabilitation facility.The brace should be worn whenever she is ambulating but canbe off for sitting lying down in bed and toileting. She mayshower and evaluation for home services should be made.Her medications are included in a list which is to long todictated at this time. This is deferred due to accuracyconcerns.She will up with Dr. [**Last Name (STitle) 363**] in 10 to 14 days.At a later time consideration for flat back syndromecorrection with posterior spinal osteotomy will be made. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3191**] [**MD Number(1) 3192**]Dictated By:[**Last Name (NamePattern1) 3193**]MEDQUIST36D: [**2179-8-29**] 14:33:42T: [**2179-8-29**] 15:38:35Job#: [**Job Number 3194**]Admission Date: [**2170-7-29**] Discharge Date: [**2170-8-2**]Date of Birth: [**2101-5-19**] Sex: FService: SURGERY
Allergies
DISEASE
:SulfonamidesAttending:[**First Name3 (LF) 3200**]Chief Complaint:
Abdominal pain
DISEASE
Major Surgical or Invasive Procedure:[**2170-7-29**] Exploratory Laparotomy SplenectomyHistory of Present Illness:69-year-old female who has had
abdominal pain
DISEASE
for some time.Shepresented with
dizziness abdominal pain hypotension
DISEASE
and
bradycardia
DISEASE
at the [**Hospital1 18**] Emergency room essentially in
shock
DISEASE
. On CT scan she was found to have a ruptured spleenwith layering of
hemorrhage
DISEASE
consistent with a large
hemoperitoneum
DISEASE
. Hematocrit on arrival was 20.3 and she wasrequiring pressor support as well as volume. As suchemergency laparotomy was indicated.Past Medical History:paroxysmal
atrial fibrillation breast cancer DVT
DISEASE
previously oncoumadin (several years ago)
PE hypothyroidism
DISEASE
chronic
leukopenia anemia
DISEASE
peripheral neuropathy depression
DISEASE
HTN HLD
hyponatremia
DISEASE
BCC
PSH
DISEASE
:lumpectomy '[**62**] hip replacement b/l lumbar diskectomyMeds:Social History:MarriedFamily History:NoncontributoryPertinent Results:[**2170-7-29**] 11:45PM PO2-527* PCO2-34* PH-7.26* TOTAL CO2-16* BASEXS--10[**2170-7-29**] 11:45PM LACTATE-1.6[**2170-7-29**] 11:38PM GLUCOSE-160* UREA N-13 CREAT-0.5 SODIUM-133POTASSIUM-2.8* CHLORIDE-109* TOTAL CO2-16* ANION GAP-11[**2170-7-29**] 11:38PM ALT(SGPT)-31 AST(SGOT)-34 ALK PHOS-46 TOTBILI-0.6[**2170-7-29**] 11:38PM WBC-13.3* RBC-4.36# HGB-13.3# HCT-38.6#MCV-88 MCH-30.4 MCHC-34.4 RDW-14.7[**2170-7-29**] 11:38PM PLT COUNT-98*[**2170-7-29**] 11:38PM PT-13.9* PTT-26.7 INR(PT)-1.2*[**2170-7-29**] 07:40PM ALT(SGPT)-11 AST(SGOT)-14 ALK PHOS-44 TOTBILI-0.2[**2170-7-29**] 07:40PM LIPASE-11[**2170-7-29**] 07:40PM ALBUMIN-2.8*IMPRESSION:1.
Splenic rupture
DISEASE
with large
hemoperitoneum
DISEASE
.
Subcentimeter
DISEASE
fociofhyperdensity in the left upper quandrant with progressiveincreasedconspicuity on venous and delayed phases favor nonarterialetiology although active arterial extravasation cannot beexcluded.2. Two right lower lobe pulmonary nodules measuring 5 and 2.5mm. In thesetting of
breast cancer
DISEASE
followup in three months isrecommended. Probable post radiation treatment changes of rightanterior lung subpleural thickening.3. Multiple foci of sclerosis within the bony pelvis mayrepresent boneislands however in the absence of priors metastatic lesionscannot beexcluded in the setting of
breast cancer
DISEASE
. Recommend comparisonto any prior outside studies. Consider bone scan if thesefindings have not already been evaluated.4. No evidence of
abdominal aortic aneurysm
DISEASE
. Extensive
atherosclerotic
DISEASE
disease.5. Nonspecific
breast calcifications
DISEASE
. Please correlate withmammographyBrief Hospital Course:She was admitted to the
ACS
DISEASE
service and after discussing therisks benefits and alternatives to emergency laparotomy andpossible splenectomy with the patient and the patient's familyshe was immediately and emergently taken to the OR. Herintraoperative course was stable. Postoperatively she wastransferred to the ICU for close monitoring. She remainedhemodynamically stable and was eventually transferred to theregular nursing unit where she continued to progress.She did have
pain
DISEASE
control issues requiring higher doses of
Dilaudid
DISEASE
as she reported an
allergy
DISEASE
to Oxycodone. She was notedto have a mild
ileus
DISEASE
felt secondary to the narcotics and wasgiven a 1 time dose of methylnaltrexone. Her diet was slowlyadvanced and she is tolerating a regular diet. She is ambulatingindependently.She received her splenectomy vaccines prior to discharge andwill follow up with Dr. [**Last Name (STitle) **] in Surgery clinic in the next1-2 weeks for removal of her staples.Medications on Admission:ARMOUR THYROID 60 MG TABS (THYROID) 2 and [**11-25**] by mouth one timedailyASA 81' valsartan 80' triamterene-hctz 75-50' OMEGA-3 1000 MGCAP' FLECAINIDE 125'' fluvastatin XL 80' nifedipine XL 30'KCl 10 mEq' vit D [**2159**] IU' COENZYME Q10 400' FOLATE 400MCG'melatonin 1 qhs prn diazepam 5'prnDischarge Medications:1. Thyroid (Pork) 90 mg Tablet Sig: One (1) Tablet PO once aday: take with 60 mg tablet to equal 150 mg.Disp:*30 Tablet(s)* Refills:*2*2. Thyroid (Pork) 60 mg Tablet Sig: One (1) Tablet PO once aday: take with 90 mg tablet to equal 150 mg tablet.Disp:*30 Tablet(s)* Refills:*2*3. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).4. Flecainide 50 mg Tablet Sig: 2.5 Tablets PO Q12H (every 12hours).5. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) TabletSustained Release PO DAILY (Daily).6. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4hours) as needed for
pain
DISEASE
.Disp:*60 Tablet(s)* Refills:*0*7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every6 hours) as needed for
pain
DISEASE
.8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)ML PO Q12H (every 12 hours) as needed for
constipation
DISEASE
.9. Pantoprazole 40 mg Tablet Delayed Release (E.C.) Sig: One(1) Tablet Delayed Release (E.C.) PO Q24H (every 24 hours).Disp:*30 Tablet Delayed Release (E.C.)(s)* Refills:*2*10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID(2 times a day).11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times aday) as needed for
constipation
DISEASE
.12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times aday).Disp:*60 Tablet(s)* Refills:*2*Discharge Disposition:Home With ServiceFacility:[**Hospital 119**] HomecareDischarge Diagnosis:Splenic ruptureDischarge Condition:Mental Status: Clear and coherent.Level of Consciousness: Alert and interactive.Activity Status: Ambulatory - Independent.Discharge Instructions:You are being discharged on medications to treat the
pain
DISEASE
fromyour operation. These medications will make you drowsy andimpair your ability to drive a motor vehicle or operatemachinery safely. You MUST refrain from such activities whiletaking these medications.Please call your doctor or return to the emergency room if youhave any of the following: * You experience new
chest pain
DISEASE
pressure squeezing or tightness.* New or worsening
cough
DISEASE
or
wheezing
DISEASE
.* If you are
vomiting
DISEASE
and cannot keep in fluids or your medications.* You are getting dehydrated due to continued
vomiting
diarrhea
DISEASE
or other reasons. Signs of
dehydration
DISEASE
include
dry
mouth
DISEASE
rapid heartbeat or feeling dizzy or faint when standing.* You see blood or dark/black material when you
vomit
DISEASE
or have a bowel movement.* You have shaking
chills
DISEASE
or a
fever
DISEASE
greater than 101.5 (F) degrees or 38(C) degrees.* Any serious change in your symptoms or any new symptoms that concern you.* Please resume all regular home medications and take any newmeds as ordered.Activity:No heavy lifting of items [**9-7**] pounds for 6 weeks. You mayresume moderateexercise at your discretion no abdominal exercises.Wound Care:You may shower no tub baths or swimming.If there is clear drainage from your incisions cover withclean dry gauze.Your steri-strips will fall off on their own. Please remove anyremaining strips 7-10 days after surgery.Please call the doctor if you have increased
pain swelling
DISEASE
redness or drainage from the incision sites.Followup Instructions:Follow up with Dr. [**Last Name (STitle) **] in [**11-25**] weeksAdmission Date: [**2139-8-20**] Discharge Date: [**2139-8-23**]Date of Birth: [**2076-7-31**] Sex: MService:CHIEF COMPLAINT: (Per patient)
Mitral valve regurgitation
DISEASE
noted on yearly physical examination.HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 3203**] is a 63 year oldmale otherwise healthy who was found to have a systolicworkup. Workup revealed
mitral regurgitation
DISEASE
approximatelytwo years ago. He had been followed serially withelectrocardiograms and was noted to have worsening
valvular
dysfunction
DISEASE
recently. He had a cardiac catheterization in[**2139-7-6**] which showed normal coronaries ejectionfraction was 66% he had 4Admission Date: [**2139-8-20**] Discharge Date: [**2139-8-23**]Date of Birth: [**2076-7-31**] Sex: MService:CHIEF COMPLAINT: (Per patient)
Mitral valve regurgitation
DISEASE
noted on yearly physical examination.HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 3203**] is a 63 year oldmale otherwise healthy who was found to have a systolicworkup. Workup revealed
mitral regurgitation
DISEASE
approximatelytwo years ago. He had been followed serially withelectrocardiograms and was noted to have worsening
valvular
dysfunction
DISEASE
recently. He had a cardiac catheterization in[**2139-7-6**] which showed normal coronaries ejectionfraction was 66% he had 4Admission Date: [**2182-2-18**] Discharge Date: [**2182-2-28**]Date of Birth: [**2109-8-28**] Sex: FService:HISTORY OF PRESENT ILLNESS: The patient was a 73-year-oldfemale admitted to the CCU on [**2182-2-18**] with
hyperkalemia
DISEASE
and
bradycardia
DISEASE
. The patient had a past medical historysignificant for
hypertension glaucoma
DISEASE
and
breast cancer
DISEASE
treated with lumpectomy XRT in [**2176**]. She was in her usualstate of health until [**12-2**] when she began to note
shortness
DISEASE
of breath. She saw her PCP and performed [**Name Initial (PRE) **] chest x-raywhich revealed a right upper lobe density. This was followedup with a CT scan which revealed a lobulated mass of 2.3 cmin the posterior segment of the right lower lobe andbilateral lobe interstitial
fibrosis
DISEASE
. Follow-up PET scan wasnondiagnostic. The patient had a mediastinoscopy whichshowed no evidence of
malignancy
DISEASE
or lymph nodes. Lung biopsywas performed which revealed
pulmonary fibrosis
DISEASE
. Subsequentspirometry revealed a mild restrictive defect. The entirepicture was thought to represent UIP.On [**2182-2-18**] she presented to the [**Hospital1 **][**First Name (Titles) 2142**] [**Last Name (Titles) **] with a
complaint
DISEASE
of
nausea vomiting
DISEASE
and
diarrhea
DISEASE
times several days. In the waiting room shedeveloped
presyncope
DISEASE
. She was urgently brought to the
trauma
DISEASE
bay there her heart rate was in the 30s with the EKGrevealing a junctional rhythm. Her SBP was in the 80s.Attempts made to place a temporary pacing wire but during theprocedure the patient suffered
respiratory arrest
DISEASE
. She wasintubated and resuscitated and a line was successfullyplaced. Subsequent labs revealed a potassium of 9.8. Thepatient was treated with calcium bicarb insulin and glucoseand admitted to CCU.In the CCU the patient was started on Levophed and dopaminefor
hypotension
DISEASE
. Swan-Ganz catheter was placed to evaluateher
hypotension
DISEASE
and revealed an SVR of 2473 with a cardiacoutput of 2.2. Two hours later the cardiac output was 6.5and SVR was 898 after pressors were weaned down. Urgent TTErevealed normal systolic function no pericardial effusion.Potassium dropped to 4.3 after 1 day. The patient wasempirically treated with vancomycin levofloxacin and Flagylfor
hypotension
DISEASE
which was thought possibly due to
sepsis
DISEASE
.By hospital day 3 she was off pressors her white bloodcount was 16.1. She was successfully extubated and herpotassium remained normal. By hospital day 4 she continuedto have mild
respiratory distress
DISEASE
despite being extubated.She was thought to be in mild
CHF
DISEASE
. She was diuresed.Levofloxacin and vancomycin were continued for possible
pneumonia
DISEASE
. By hospital day 5 she developed worsening
respiratory distress
DISEASE
and the patient agreed to electiveintubation. She was then transferred to the MICU for furtherworkup and care.PAST MEDICAL HISTORY:
Hypertension
DISEASE
.
Glaucoma
DISEASE
.
Breast cancer
DISEASE
.UIP.ALLERGIES: No known
drug allergies
DISEASE
.MEDICATIONS ON ADMISSION:1. Verapamil.2. Propranolol.3. Tamoxifen.4. Xalatan eye drops.5. Betoptic eye drops.6. Calcium carbonate.7. Aspirin.8. Folate.9. Vitamin E.PHYSICAL EXAMINATION: On admission to the MICU temperature98.9 degrees blood pressure 126/61 and pulse 108. Thepatient was sedated and intubated. Her lungs revealeddiffuse crackles bilaterally. Cardiac exam was within normallimits. Abdomen was benign. Lower extremity revealed no
edema
DISEASE
.PERTINENT LABORATORY DATA: On admission to the MICU includeda white count of 21.9 hematocrit of 29.3 and platelets of85.Chest x-ray on admission to MICU revealed persistentbilateral upper lobe patchy
opacities
DISEASE
may represent
interstitial edema
DISEASE
plus aspiration. Continued patchyatelectasis within the left lower lobe and small left pleuraleffusion.CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admittedto the Medical Intensive Care Unit with presumed diagnosis of
sepsis
DISEASE
. Subsequently she developed a picture consistentwith
ARDS
DISEASE
and required multiple pressors. After several daysin the CCU she was on 3 different pressors and was unable tomaintain her blood pressure. She was requiring increasingventilatory support. A discussion was held with the familywho decided that the patient will be made DNI/DNR due to thefact that CPR was likely to be unhelpful if the patientarrested. On [**2182-2-28**] at 03:15 p.m. the patient waspronounced dead. The family was at the bedside.CONDITION ON DISCHARGE: Expired.DISCHARGE STATUS: Expired.DISCHARGE MEDICATIONS: None.FOLLOW UP PLAN: None.DISCHARGE DIAGNOSES:
Septic shock
DISEASE
.
Respiratory failure
DISEASE
.
Hyperkalemia
DISEASE
causing
cardiopulmonary arrest
DISEASE
. DR.[**Last Name (STitle) 2466**][**First Name3 (LF) 2467**] 12-746Dictated By:[**Last Name (NamePattern4) 2464**]MEDQUIST36D: [**2182-6-21**] 16:34:53T: [**2182-6-21**] 19:31:08Job#: [**Job Number 2468**]Admission Date: [**2120-8-14**] Discharge Date: [**2120-8-19**]Date of Birth: [**2059-6-19**] Sex: FService: NeurosurgeryHISTORY OF PRESENT ILLNESS: The patient is a 61-year-oldfemale with a history of brain
tumor
DISEASE
. MRI scan showed rightcerebellar mass.PAST MEDICAL HISTORY: Past medical history includes breast
cancer
DISEASE
with lumpectomy in [**2114**] carpal tunnel syndrome sleep
apnea gastroesophageal reflux disease
DISEASE
.PAST SURGICAL HISTORY: Previous surgery included lumpectomyin [**2114**] hysterectomy in [**2114**] thyroid nodule excision.ALLERGIES: The patient had no known drug
allergies
DISEASE
.PHYSICAL EXAMINATION ON ADMISSION: On physical examinationthis was an obese woman in no acute distress. HEENT wasanicteric. A well-healed incision. Chest was clear toauscultation. Cardiac revealed S1 and S2 a regular rate andrhythm. Abdomen was obese soft a well-healed midlineincision. Extremities revealed slight
edema
DISEASE
of the bilaterallower extremities nonpitting easily palpable dorsalis pedisand posterior tibialis pulses.HOSPITAL COURSE: The patient was admitted on [**2120-8-14**] status post right suboccipital craniotomy for resectionof
cerebellar mass
DISEASE
. There were no intraoperativecomplications.Postoperatively the patient was monitored in the SurgicalIntensive Care Unit where she was awake alert and orientedtimes three moved all extremities with good strength. Nodrift. Lungs were clear to auscultation. A regular rate andrhythm.The patient was transferred to the regular floor onpostoperative day one in stable condition. Her face wassymmetric.
Extraocular movements
DISEASE
were full. Followed 3-stepcommands awake alert and oriented times three. Thepatient was seen by Physical Therapy and found to requirethree to four days of Physical Therapy treatment prior todischarge to home. The patient did receive that treatmentand is now stable for discharge home.MEDICATIONS ON DISCHARGE: Her medications at the time ofdischarge were Decadron taper off over two weeks timePercocet one to two tablets p.o. q.4h. p.r.n Zantac 150 mgp.o. b.i.d. She is also on Lopressor 50 mg p.o. b.i.d.DISCHARGE DISPOSITION: Vital signs were stable and thepatient was afebrile at the time of discharge.DISCHARGE FOLLOWUP: The patient was to follow up in theBrain [**Hospital 341**] Clinic in one week for staple removal and followup in the Brain [**Hospital 341**] Clinic with Dr. [**First Name (STitle) **].CONDITION AT DISCHARGE: Her condition was stable at the timeof discharge. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**] M.D. [**MD Number(1) 343**]Dictated By:[**Last Name (NamePattern1) 344**]MEDQUIST36D: [**2120-8-19**] 10:01T: [**2120-8-21**] 13:47JOB#: [**Job Number 3206**]Admission Date: [**2121-8-1**] Discharge Date: [**2121-8-5**]Date of Birth: [**2059-6-19**] Sex: FService:HISTORY OF PRESENT ILLNESS: The patient is a 62-year-oldright handed African-American woman with metastatic
breast
cancer
DISEASE
to the brain. She is status post a resection of theright cerebellum
metastasis
DISEASE
by Dr. [**First Name (STitle) **] on [**2120-8-14**] and wasfollowed by stereotactic radiosurgery. Spinal tap was donein [**2120-9-16**] but the cytology was negative. A chest CTrevealed
pulmonary metastases
DISEASE
and she has been treated withchemotherapy since [**2120-10-17**]. The patient developedsymptoms of
loss of balance slurred speech
DISEASE
and doublevision. An MRI was done which revealed
cerebellum metastasis
DISEASE
and possible leptomeningeal spread. A chest x-ray from[**2121-7-1**] showed an increase in lung nodules.PHYSICAL EXAM:VITAL SIGNS: Blood pressure 148/84 pulse 84 respiratoryrate 18 temperature 96.6Admission Date: [**2118-9-9**] Discharge Date: [**2118-9-14**]Date of Birth: [**2050-12-3**] Sex: FService: MEDICINE
Allergies
DISEASE
:aspirin / amlodipine / BenadrylAttending:[**First Name3 (LF) 5141**]Chief Complaint:
Hypotension
DISEASE
requiring ICU admissionMajor Surgical or Invasive Procedure:EndoscopyHistory of Present Illness:67yo F w/
Uterine carcinosarcoma
DISEASE
s/p XRT/surgery sent to the EDfrom [**Hospital **] clinic because of low BPs. Acute onset ofnausea/vomiting. No fevers/chills/abdominal pain/neck stiffness.
Hypotensive
DISEASE
to 64/22 in the ED. No
pericardial effusion
DISEASE
. Admission Date: [**2128-3-14**] Discharge Date: [**2128-3-23**]Service: NEUROLOGY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2518**]Chief Complaint:large
intraparenchymal bleed
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Patient is a [**Age over 90 **] yo woman with PMH of
dementia obesity OA DM2
DISEASE
HTN cataracts
DISEASE
falls
CRF Anemia
DISEASE
DNR/DNI and active UTI whosuffered a fall at [**Hospital 100**] Rehab today. She is primarily Russianspeaking but also speaks some English. She was heard to fallin the bathroom at 0800. Patient denied LOC and was without anyapparent injury. She was put back in bed. some timethereafter she was noted to have dysarhtira left facial droopand
flaccid left hemiparesis
DISEASE
in the left arm. She wastransfered to [**Hospital1 18**] for presumed
CVA
DISEASE
.She reports to me that she fell and endorses
pain
DISEASE
in her headand her lower back. She endorses that she fell around the timeof the
pain
DISEASE
but she cannot communicate the exact sequence ofevents.At baseline she is demented but very active walking with walkerand conversant. She has recently been getting treatment for
UTI
DISEASE
with Levaquin. Her proxy [**Name (NI) 3535**] reports that her family noticedsome mild
speech impairments
DISEASE
last week but no focal weakness.This however was around the time of the positive UA and may havebeen related to
infection
DISEASE
.ROS: she is unable to offer full ROS. She is known to haveacitve
UTI
DISEASE
and she does endorse
headache
DISEASE
and
LBP
DISEASE
.Past Medical History:
dementia obesity OA DM2 HTN cataracts
DISEASE
falls
CRF Anemia
DISEASE
Social History:She lives at [**Hospital 100**] Rehab. Her proxy is relative [**Name (NI) 3535**][**Name (NI) 5148**] who can be reached at [**Telephone/Fax (1) 5149**]. Cell:[**Telephone/Fax (1) 5150**].Family History:N/cPhysical Exam:T- 98 BP- 142-173/53-80 HR- 72 RR- 14 O2Sat 100 2lGen: Lying in bed NADHEENT: NC/AT moist oral mucosaNeck: Cervical collar in placeBack: No skin changes. No point tenderness entire spine andpelvis.CV: RRR Nl S1 and S2 moderate soft ejection murmur.Lung: Clear to auscultation bilaterallyaBd: Admission Date: [**2107-7-19**] Discharge Date: [**2107-7-27**]Date of Birth: [**2070-10-23**] Sex: FService: GYN
Allergies
DISEASE
:FlagylAttending:[**First Name3 (LF) 5158**]Chief Complaint:
Abdominal Pain
DISEASE
at 6 [**5-2**] wks Gestation w/ Known R EctopicPregnancyMajor Surgical or Invasive Procedure:1) s/p Exploratory laparotomy lysis of adhesions rightsalpingo-oophorectomy for
ruptured ectopic pregnancy
DISEASE
2) CT Angiogram ([**2107-7-21**]) revealing Nonocclusive pulmonaryembolus at the right main pulmonary artery bifurcation.3) s/p Heparin tx (coupled w/ Coumadin) for tx of pulmonaryembolusHistory of Present Illness:HPI:36yo G3P2002 at 6 6/7wk known ectopic pregnancy representsto ED w/ increasing intermittent sharp
stabbing pain
DISEASE
in lowerabd starting last night. No radiation of
pain
DISEASE
nothing makes
pain
DISEASE
less or worse. Pt denies f/c n/v cp/sob dysuria/hematuriaVB. Pt states the her
pain
DISEASE
was the worst at her initialpresentation on [**2107-7-10**]. Pt was originally xfered from Good[**Hospital 5159**] Hospital w/ Admission Date: [**2139-10-17**] Discharge Date: [**2139-10-24**]Date of Birth: [**2087-5-17**] Sex: FService: NEUROLOGY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 5167**]Chief Complaint:increased [**First Name3 (LF) 862**]Major Surgical or Invasive Procedure:lumbar punctureHistory of Present Illness:The pt is a year-old woman with a PMH s/f MS [**First Name (Titles) **] [**Last Name (Titles) 862**] D/Oincluding a history of
status epilepticus
DISEASE
who presented to[**Hospital6 5168**] on the evening of [**2139-10-16**] with chief
complaint
DISEASE
of found unresponsive. History obtained from sisterand from OSH records. The patient was at home and had a fallwhich was not unusual. She seemed fine after the fall. She wasfound unresponsive at 8:30pm and brought to the OSH. She wasnoted to have
seizures
DISEASE
at the OSH by the sister. She was alsonoted to be
Febrile
DISEASE
to 101. She had an elevated white count.[**Date Range **] was managed with ativan (unknown how much)andphosphenytoin 1000mg x1. An EEG on [**2139-10-17**] showed rare Lefttemporal sharps but no
seizures
DISEASE
. The
fever
DISEASE
workup includedUA/UCx BCx chest x-ray non contrast head CT and an LP. Noneof these was revealing. The patient was felt to be in aprotracted post-ictal state. A decision was made to transferthepatient to the [**Hospital1 18**] for further management. The patient wasputon a propofol gtt given fentanyl and intubated for airwayprotection given the concern that she might seize en route.Past Medical History:-Complex partial
seizures
DISEASE
(
staring spells
DISEASE
and arm extension).Shehad status 10 yrs ago-Demyelinating disease by MRI and oligoclonal bands on LP in[**2119**].-Depression and h/o SI-Restless legs-h/o mumpsSocial History:Patient lives with her eldest sister and her 82 year old motherin [**Name (NI) 5169**] MA where she was born. She is one of six childrenhaving 4 sisters and 1 brother. She describes her family asbeing extremely close and supportive of her. She is very closeto her mother and is upset about being away from her during thishospitalization. She is unemployed at this time due to physicaland cognitive limitations related to her disease. She worked asa horticulturist doing research in [**State 4565**] and [**State 5170**] inthe past. She is divorced but remains on good terms with herformer husband who lives in CA. She has no children. She hasno history of IV drug use tobacco use or alcohol consumption.Family History:Father died of a
myocardial infarction
DISEASE
. Mother is alive and at82 years of age is in good health. One sister is 42 and alsosuffers from a
demyelinating disease
DISEASE
(suspected multiplesclerosis) which has affected her cognition more than her motorand sensory systems. This sister has responded well toSolumedrol infusions and Rebif in the past with resolved speechand swallowing problems. [**Name (NI) **] had one paternal uncle withsuspected
multiple sclerosis
DISEASE
(diagnosed at age 27 died at 42)another paternal uncle with
paranoid schizophrenia
DISEASE
anotherpaternal uncle who died of
stroke
DISEASE
in his 40Admission Date: [**2119-4-23**] Discharge Date: [**2119-4-25**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 106**]Chief Complaint:STEMI s/p stenting of LADMajor Surgical or Invasive Procedure:Cardiac catheterization s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) 5175**]History of Present Illness:Pt is a 89 yo male with CAD s/p cath [**5-/2107**] (90% stenosis
LAD
DISEASE
s/patherectomy)
dementia CHF DM
DISEASE
CRI presents to OSH with
tachypnea
DISEASE
found to have an STEMI and transferred to [**Hospital1 18**] forcath. Pt presented to an OSH with SOB from his nursing home. Hehad received 20 mg IV lasix prior to arrival at OSH per report.Pt told OSH ED he had been Admission Date: [**2123-2-2**] Discharge Date: [**2123-2-4**]Date of Birth: [**2067-12-29**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4219**]Chief Complaint:Vague diffuse abdominal discomfortMajor Surgical or Invasive Procedure:noneHistory of Present Illness:55 yo M with h/o chronic EtOH abuse
HTN
DISEASE
Unit No: [**Numeric Identifier 5181**]Admission Date: [**2139-6-6**]Discharge Date: [**2139-6-13**]Date of Birth: [**2069-9-23**]Sex: FService: [**Last Name (un) **]HISTORY OF PRESENT ILLNESS: The patient is a 69 year oldwoman with history of
alcoholic hepatitis
DISEASE
and
GERD
DISEASE
whopresented with sudden onset of
abdominal pain
DISEASE
mostlyepigastric accompanied by some
nausea
DISEASE
and
vomiting chills
DISEASE
no
fevers
DISEASE
.
Last bowel movement
DISEASE
was the day prior. She waspassing gas. No
chest pain
DISEASE
no
shortness of breath
DISEASE
. No
melena
DISEASE
.PAST MEDICAL HISTORY:1.
Alcoholic hepatitis
DISEASE
.2.
Hypertension
DISEASE
.3.
Gastroesophageal reflux disorder
DISEASE
.4.
Hypercholesterolemia
DISEASE
.5.
Anxiety
DISEASE
.6. History of
ventral hernia
DISEASE
repair.ALLERGIES: Sulfa.MEDICATIONS:1. Atenolol 100 mg daily.2. Hydrochlorothiazide 25 mg a day.3. Multivitamin.4. Prilosec 40 mg a day.5. Folic acid 1 mg a day.6. Protonix 40 mg a day.PHYSICAL EXAMINATION: Pleasant cooperative in milddistress. Regular rate and rhythm. Clear to auscultationbilaterally. Abdomen is soft tender to palpation ino theepigastric area. Rectal exam - guaiac negative no masses.Labs include white blood cell count of 17 hematocrit of 44BUN of 7 creatinine of 0.9. AST is 106 ALT 419 alkalinephosphatase 147 total bilirubin 4.4. Amylase 850 lipase3234. LDH 408.STUDIES: CT of the abdomen showed
pancreatitis
DISEASE
with regionsof relative hypo enhancement in the pancreas a distendedgallbladder with stone and distended cystic duct. No
intrahepatic ductal
DISEASE
dilation.HOSPITAL COURSE: The patient was admitted to the ICU and wastreated with fluid resuscitation. NPO. Gastroenterologyconsultation was obtained. By the next day her enzymes wereimproved. The ERCP was held in consideration that thepatient had probably already passed the stone and was nowimproving. Her abdominal examination and her labs continuedto improve until [**2139-6-8**] when already on the floor thepatient started complaining of increased
abdominal pain
DISEASE
. Theabdomen showed some distension and the patient's hematocritdropped down from 31 to requiring blood transfusion. Sheunderwent emergent CT scan which showed
pseudoaneurysm
DISEASE
inadjacent to an
SMA
DISEASE
. The patient underwent angio whichrevealed a
pseudoaneurysm
DISEASE
which was coming off from branchesfrom the
SMA
DISEASE
as well as having a feeder from PDA. They wereable to embolize this
pseudoaneurysm
DISEASE
as well as embolize thefeeder from
SMA
DISEASE
but not from the PDA.The patient returned to the ICU where her blood pressure wasinitially controlled with nitroglycerin drip. Over the nextcouple of days the patient's condition has improved. Herhematocrit remains stable. It was not requiring anytransfusion. Her abdomen although still mildly distendedwas soft. She was passing gas and having
bowel movements
DISEASE
. Herdiet was advanced initially to clears and the patient wentto a regular diet which she tolerated well. She started toambulate initially with help then on her own. She wastransferred to the floor. The vascular service was consulted.Their CT was obtained on [**2139-6-8**] which showed nochanges in the
pseudoaneurysm
DISEASE
with hematocrits remainingstable. The patient was otherwise doing fine. The feeling wasthat the patient does not need any procedures at this point.On [**2139-5-13**] the patient is afebrile. Vital signs arestable. The abdomen is soft non distended. Tolerating aregular diet and ambulating without help. No concerns.CONDITION ON DISCHARGE: Good.DISPOSITION: The patient is discharged home. The patientwill follow up with Dr. [**Last Name (STitle) 5182**] in 2 weeks for discussingcholecystectomy at a later date. The patient will also followup with Dr. [**Last Name (STitle) **] next week.DISCHARGE MEDICATIONS:1. Tylenol 1-2 tabs p.o. every 4-6 hours p.r.n.
pain
DISEASE
.2. Ativan 1 mg p.o. at bedtime p.r.n..3. Protonix 40 mg p.o. daily.4. Lopressor 75 mg p.o. daily.DISCHARGE DIAGNOSES:1.
Gallstone pancreatitis
DISEASE
.2.
Hypertension
DISEASE
.3.
Gastroesophageal reflux disorder
DISEASE
.4.
Alcoholic hepatitis
DISEASE
.5.
Hypercholesterolemia
DISEASE
.6.
Anxiety
DISEASE
.7. SMA
pseudoaneurysm
DISEASE
status post
bleeding
DISEASE
and embolization. [**Name6 (MD) 5183**] [**Last Name (NamePattern4) 5184**] [**MD Number(1) 5185**]Dictated By:[**Doctor Last Name 5186**]MEDQUIST36D: [**2139-6-13**] 12:11:22T: [**2139-6-13**] 12:51:11Job#: [**Job Number 5187**]Admission Date: [**2144-6-9**] Discharge Date: [**2144-6-13**]Date of Birth: [**2087-3-16**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1928**]Chief Complaint:
Suicide
DISEASE
Attmpt/OverdoseMajor Surgical or Invasive Procedure:None.History of Present Illness:57 year-old female with
depression
DISEASE
prior suicidal attempts
diabetes mellitus type II
DISEASE
admitted with suicide attempt. Shereports feeling more
depressed
DISEASE
than baseline recently. She triedto relieve pain/stress with left arm laceration few days ago andsuicide attempt by trying to crash her car yesterday. Thismorning she took methadone 120mg PO (from a friend) trazodonex4 tablets gabapentin 300mg PO x 15 tablets. She does notrecall events following ingestionAdmission Date: [**2143-11-22**] Discharge Date: [**2143-11-25**]Date of Birth: [**2075-10-18**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 898**]Chief Complaint:Reason for ICU admission: ROMI coffee ground
emesis
DISEASE
Major Surgical or Invasive Procedure:endoscopyHistory of Present Illness:HPI:68 y.o. man with
HTN
DISEASE
presented to PCP for routine visit on dayof admission c/o 2 months of worsening DOE and chest pressurewith exertion. He reports having a stress test 1 year ago whichwas stopped after 3 minutes for
hypertension
DISEASE
(SBP in the 230s).He had no symptoms and no ST wave changes. In addition hecomplains of severe
heartburn
DISEASE
(different than his chestpressure) intermittently every few days x 3 months along with
violent coughing fits
DISEASE
which cause him to
vomit
DISEASE
dark brownliquid. He denies frank blood in his
emesis
DISEASE
. The
heartburn
DISEASE
isworse at night with lying flat. He denies NSAID use but doesadmit to drinking at least [**2-9**] drinks of burbon daily..He was referred to the ED for concern of
ACS
DISEASE
. In the ED he wasafebrile HR 70s BP 116/73m RR 16 and 97%
RA
DISEASE
. Hct was 41. Histrop was negative but ECG showed TWI in V1-V3 which were new. Hewas given ASA 325 Lopressor and started on nitroglycerin andheparin gtt. Became
hypotensive
DISEASE
with nitro to SBP 80s BPresponded to 2L NS. He then started to
vomit
DISEASE
brown colored
guiac positive emesis
DISEASE
. The heparin and nitro drips were stopped.He was given IV protonix and Reglan. He was admitted to MICU forfurther monitoring/ROMI..ROS:
Denies fever chills
DISEASE
. No h/o
blood clot
DISEASE
or recent travel..Past Medical History:PMH:
HTN
DISEASE
ETOH abuseh/o
perianal abscess
DISEASE
CKD
DISEASE
baseline Cr 1.3-1.4
Glaucoma
DISEASE
.Social History:Social hx: Lives with his partner (male). Retired budjet analystfor park service. Has history of alchoholism quit for 20 yrsthen starting drinking again when he retired but much less.Drinks 2-3 glasses burbon daily more when with friends. Startsdrinking around 5pm. Former smoker Admission Date: [**2120-11-23**] [**Month/Day/Year **] Date: [**2120-11-26**]Date of Birth: [**2067-8-13**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 348**]Chief Complaint:weaknessMajor Surgical or Invasive Procedure:noneHistory of Present Illness:53 M with CAD ischemic
CM
DISEASE
with
depressed
DISEASE
systolic EF (20%)
diabetes
DISEASE
and h/o PE on anticoagulation who presented to ED withLE
weakness
DISEASE
and feeling unwell where he was found to be in
ARF
DISEASE
complicated by
hyperkalemia
DISEASE
. States that he started to feelunwell a few days ago. Has been suffering with frequent loose
bowel movements
DISEASE
a day during the past 4 daysAdmission Date: [**2151-11-8**] Discharge Date: [**2151-11-10**]Date of Birth: [**2085-10-20**] Sex: MService: UROLOGY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4533**]Chief Complaint:BPHMajor Surgical or Invasive Procedure:TURP [**2151-11-8**]History of Present Illness:The patient is a 66-year-old male who underwent 2 procedures atan outside hospital for treatment of BPH and now presents withrecurrent symptoms.Past Medical History:BPH
arthritis
DISEASE
GERD gastric
ulcers depression anxiety
DISEASE
Social History:He smokes [**11-24**] pack per day and does not drink alcohol.Family History:Non-contributoryPhysical Exam:On Discharge:VS: Temp 97.7 HR 72 BP 102/60 RR 18 O2 sat 95% on room airGen: NAD alert and orientedCV: RRRPulm: clear bilaterallyAbd: soft nontender nondistendedGU: foley with light pink urinePertinent Results:Post-op CBC:[**2151-11-8**] 02:48PM BLOOD WBC-7.6 RBC-4.99 Hgb-15.7 Hct-45.9 MCV-92MCH-31.5 MCHC-34.2 RDW-13.2 Plt Ct-182Work up for altered mental status:[**2151-11-9**] 05:23PM BLOOD WBC-7.6 RBC-4.17* Hgb-12.9* Hct-37.9*MCV-91 MCH-31.0 MCHC-34.1 RDW-13.7 Plt Ct-139*[**2151-11-9**] 05:23PM BLOOD Neuts-83.2* Lymphs-9.7* Monos-4.9 Eos-2.1Baso-0[**2151-11-9**] 05:23PM BLOOD PT-14.0* PTT-29.1 INR(PT)-1.2*[**2151-11-9**] 05:23PM BLOOD Glucose-100 UreaN-13
Creat-0.8
DISEASE
Na-144K-3.5 Cl-115* HCO3-22 AnGap-11[**2151-11-9**] 05:23PM BLOOD ALT-8 AST-13 LD(LDH)-116 AlkPhos-48Amylase-30 TotBili-0.7[**2151-11-9**] 05:23PM BLOOD Lipase-15[**2151-11-9**] 12:01PM BLOOD CK-MB-4 cTropnT-Admission Date: [**2146-3-29**] Discharge Date: [**2146-4-6**]Date of Birth: [**2071-5-3**] Sex: FService: GEN [**Doctor First Name 147**]HISTORY OF PRESENT ILLNESS: [**Known firstname 5199**] [**Known lastname 2405**] was a 74 yearold female with a history of
diverticulitis
DISEASE
who was in herusual state of health until the [**10-28**] when shepassed three
bloody bowel movements
DISEASE
. She also experiencedleft lower quadrant
pain
DISEASE
and a gush of bright red blood perrectum which was recorded twice more with resulting
symptomatology
DISEASE
between episodes. She was admitted by herprimary care physician to the hospital after having a drop inher hematocrit of 5 points from 34.8 to 29 at an outsidehospital in 24 hours.PAST MEDICAL HISTORY:1. Parathyroidectomy in [**2116**].2. Status post hysterectomy in [**2110**].3. Nephrolithiasis.4. History of
diverticulosis
DISEASE
.5. History of iron deficiency anemia.6. Glaucoma.7. Hiatal
hernia
DISEASE
.8. Recurrent H. pylori which has just been treated.9. Anal-rectal
fistula
DISEASE
.10.
Arthritis
DISEASE
.MEDICATIONS ON TRANSFER:1. Zestril 40 mg p.o. q. day.2. Zantac 300 mg p.o. twice a day.3. Detrol CA 1 mg p.o. q. day.4. Xalatan one gtt q. h.s.5. FESO4 325 mg twice a day.6. Cosopt one drop o.u. twice a day.ALLERGIES: No known
drug allergies
DISEASE
.SOCIAL HISTORY: The patient is married with no tobacco orethanol use.FAMILY HISTORY: Notable for
colon cancer
DISEASE
.PHYSICAL EXAMINATION: On examination the patient wasafebrile with stable vital signs. Heart rate of 96Admission Date: [**2166-2-19**] Discharge Date: [**2166-2-26**]Date of Birth: [**2092-12-30**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:IodineAdmission Date: [**2166-4-1**] Discharge Date: [**2166-4-7**]Date of Birth: [**2092-12-30**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:IodineAdmission Date: [**2182-9-16**] Discharge Date: [**2182-9-20**]Date of Birth: [**2107-2-27**] Sex: MService:NOTE - An addendum will be dictated when the patient isdischarged.HISTORY OF PRESENT ILLNESS: The patient is a 75 year oldmale with a past medical history significant for coronary
artery disease diabetes
DISEASE
and
chronic renal insufficiency
DISEASE
admitted to Coronary Care Unit following cardiaccatheterization for ventilatory support and Intensive CareUnit monitoring. The patient originally presented to anoutside hospital the morning of admission complaining of
chest pain
DISEASE
and symptoms of
congestive heart failure
DISEASE
. Anelectrocardiogram showed a new left
bundle branch block
DISEASE
. Hewas then transferred to [**Hospital6 256**]for emergent cardiac catheterization. The patient wentimmediately to the Catheterization Laboratory upon arrival.Catheterization showed three
vessel coronary artery disease
DISEASE
patent graft left internal mammary artery to the leftanterior descending patent saphenous vein graft to theposterior descending artery and patent saphenous vein graftto obtuse marginal 1. It was significant for increased rightand left filling pressures. Angioplasty was then performedon the aortoiliac bypass graft left circumflex coronaryartery with failed angioplasty of obtuse marginal 1. Thepatient developed significant
respiratory distress
DISEASE
followingcatheterization and was ventilated for ventilatory supportwith transfer to the Coronary Care Unit on a ventilator.PAST MEDICAL HISTORY: Coronary
artery disease
DISEASE
status postcoronary artery bypass graft redo three vessels in [**2159**]four vessels in [**2170**]
diabetes mellitus
DISEASE
times 13 years
chronic renal insufficiency
DISEASE
with baseline creatinine 2.3
prostate cancer
DISEASE
diagnosed in [**2171**] refractory to hormonetherapy followed by Dr. [**Last Name (STitle) **]
gout depression anemia
DISEASE
congestive heart failure
DISEASE
with unknown ejection fraction.SOCIAL HISTORY: History of tobacco use 30 pack years quitin [**2158**] occasional alcohol.HOME MEDICATIONS:1. Calcitriol .25 mcg q. day2. Calcium acetate 657 mg t.i.d.3. Docusate 100 mg b.i.d.4. Epogen 10000 units subcutaneous q. Thursday5. Felodipine 5 mg q. day6. Iron 325 mg t.i.d.7. Fluoxetine 20 mg q. day8. Glipizide 5 mg q. AM9. Hydralazine 40 mg b.i.d.10. Hydroxyzine 25 mg b.i.d.11. Metoprolol 25 mg t.i.d.12. Omeprazole 40 mg q. day13. Senna two tablets b.i.d.14. Simvastatin 20 mg q. day15. Allopurinol 50 mg q. day16. Isosorbide mononitrate 60 mg q. day17. Lasix 60 mg b.i.d.PHYSICAL EXAMINATION ON ADMISSION: Vital signs temperature96 heartrate 60 blood pressure 179/57 oxygen saturation100% on 30% FIO2 weight 108 kg. General: Elderly male inno acute distress. Head eyes ears nose and throat pupilsequal round and reactive to light and accommodation.Oropharynx clear. Neck supple. No
lymphadenopathy
DISEASE
. Chestclear to auscultation anteriorly no wheezes. Heart regular
rhythm II/VI systolic murmur
DISEASE
at the lower left sternalborder with no radiation. Abdomen soft nontendernondistended positive bowel sounds. Extremities 1Admission Date: [**2182-9-16**] Discharge Date: [**2182-9-29**]Date of Birth: [**2107-2-27**] Sex: MService: CCUADDENDUM: The current summary will cover hospital stay from[**2182-9-20**] through [**2182-9-29**].1. GASTROINTESTINAL BLEED: The patient developedprogressive
throat and esophageal pain
DISEASE
and had an episode of
hematemesis
DISEASE
in which he vomited approximately 500 cc ofblood. GI was consulted. The patient had an EGD whichshowed
esophagitis
DISEASE
consistent with likely ischemic changes.The patient was intubated for the EGD and transferred to theICU for closer monitoring. He was started on a Pantoprazoledrip. Following several days of the drip he was transferredover to p.o. Pantoprazole and his diet was slowly advanced.He did not have any further episodes of
hematemesis
DISEASE
and histhroat discomfort resolved.2. RENAL FAILURE: The patient was admitted with baseline
chronic renal insufficiency
DISEASE
and symptoms of
uremia
DISEASE
over theprevious three months. During the hospitalization he had anacute bump in his creatinine thought to be
ATN
DISEASE
fromcatheterization dye load. Renal consulted and the patientwas started on dialysis on [**2182-9-24**]. He underwentseveral hemodialysis sessions to remove excess fluid and thenwas started on a regimen of hemodialysis three times eachweek. The patient tolerated dialysis well.3. ACUTE CORONARY SYNDROME: The patient had a
non-ST
DISEASE
elevation MI on [**2182-9-21**]. Given his acute GI
bleed
DISEASE
he was not a candidate for anticoagulation and insteadwas managed medically. He was established on a regimen ofCarvedilol Captopril hydralazine and Isordil and was alsostarted on aspirin. The plan is to start the patient onPlavix when he is further out from his
GI bleed
DISEASE
. His cardiacmedications were titrated up as tolerated throughout hishospitalization.4. INFECTIOUS DISEASE: The patient was treated for C.
difficile colitis
DISEASE
with a ten day regimen of Flagyl. He alsodeveloped an
Enterococcus UTI
DISEASE
and was successfully treatedwith Levaquin.CONDITION ON DISCHARGE: Stable.DISCHARGE STATUS: The patient was discharged torehabilitation.DISCHARGE DIAGNOSIS:1. Non-ST elevation
myocardial infarction
DISEASE
.2. Cardiac catheterization.3. Chronic
renal insufficiency
DISEASE
with
acute renal failure
DISEASE
requiring hemodialysis.4. Clostridium
difficile colitis
DISEASE
.5. Urinary tract infection.6. ischemic esophagitis.DISCHARGE MEDICATIONS:1. Docusate 100 mg b.i.d.2. Fluoxetine 20 mg q.d.3. Hydroxyzine 25 mg b.i.d.4. Simvastatin 20 mg q.d.5. Isosorbide dinitrate 20 mg t.i.d.6. Aspirin 81 mg q.d.7. Viscous lidocaine 2% 20 ml t.i.d. p.r.n.8. Pantoprazole 40 mg p.o. q. 12 hours.9. Calcium acetate 1334 mg p.o. t.i.d. with meals.10. Carvedilol 50 mg p.o. b.i.d.11. Sliding scale insulin.12. Lisinopril 20 mg p.o. q.d.13. Metoclopramide 5 mg IV q. eight hours p.r.n.14. Metronidazole 500 mg t.i.d. times one week.FOLLOW-UP PLANS: The patient is to follow-up with primarycare doctor in one week. Follow-up with GI in two weeks forrepeat EGD. [**Name6 (MD) **] [**Name8 (MD) **] M.D. [**MD Number(1) 5214**]Dictated By:[**Last Name (NamePattern1) 5212**]MEDQUIST36D: [**2182-9-29**] 01:48T: [**2182-9-29**] 14:20JOB#: [**Job Number 5215**]Admission Date: [**2139-6-23**] Discharge Date: [**2139-6-24**]Date of Birth: [**2086-1-10**] Sex: MService: NEUROLOGY
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 5018**]Chief Complaint:L sided weakness and IPHMajor Surgical or Invasive Procedure:noneHistory of Present Illness:Mr. [**Name14 (STitle) 5229**] is a 53 yo Right-handed male patient with h/o HIVHCV recent
septic arthritis
DISEASE
on Cefazoline IV and Lovenoxprophylaxis who was transferred from [**Hospital3 4107**] due to L
hemiparesis
DISEASE
. Last night at 3AM patient reports having L
weakness
DISEASE
when hegot up to use the bathroom( able to go to bathroom normally at2AM). Patient states that he could not move his L arm and leg atall and needed assistance from his father to go back to bed. Hewas unable to sit or stand unsupported. He was aware of hisdeficits but did not want to go to the ED because of a badexperience recently at [**Hospital1 2025**]. Later in the morning patient wasfound to have L
hemiplegia
DISEASE
by visiting nurse and transferred to[**Hospital3 4107**] and [**Hospital1 18**] due to
intracranial hemorrhage
DISEASE
onCT-scan. At OSH patient was normotensive afebrile. He wasgivenAtivan 2 mg per unclear reason possibly
anxiety
DISEASE
as patientdenies any
convulsions
DISEASE
. The patient was alert and orientedduringambulance ride but became more drowsy unclear about the timingin relation to receiving Ativan. Patient was evaluated by neurology team at 10AM. Appears tobedrowsy but arousable and cooperative. Reports that he cannotmovehis L extremities at all which is stable from onset at 3am.ROS:Positive for
chills sweats chronic numbness
DISEASE
of toes R knee
pain
DISEASE
Negative
fevers headache diplopia vision loss tingling loss
DISEASE
bowel/bladder control
chest pain
DISEASE
SOB N/V.Past Medical History:1. HIV on Abacavir Truvada and Raltegravir. Diagnosed [**2125**] hereports seeing PCP monthly and recent CD4 count 600s.2. HCV on Ribavarin and Peginterferon3. Recent
septic arthritis
DISEASE
s/p arthroscopy [**2139-5-15**]. Currently onCefazolin IV 2000mg q8hr. Per patient medication was startedsince discharge from [**Hospital1 2025**] on [**2139-5-18**] and the last dose was lastnight(Need medical record from [**Hospital1 2025**]) On Lovenox prophylaxis.Social History:Living at home with his father denies currentcig smoking or alcohol in 23 years but prior history of heroinuse.Family History:knee surgery in his fatherPhysical Exam:Physical Exam on Admission:VS: T: 97.5 HR 104 BPP 152/77 RR 17 02 96/RAGeneral: Middle age patient Lying in bed looks drowsy butarousableHEENT: no
jaundice
DISEASE
no
nuchal rigidity
DISEASE
OP clear no carotid
bruits
DISEASE
Lung: clear no crackles no
wheezing
DISEASE
Heart: Systolic murmur at USBAb: soft
NT/ND
DISEASE
Ext: R knee with sutures in place warm to touch compared toleftside no
erythema
DISEASE
or drainage. L toes bandaged.Neurologic Examination:Mental status:Level of Arousal: Awake. Drowsy throughout exam but easilyarousable to voice. Oriented to [**2139-6-5**] (thought date was 13or 14Admission Date: [**2176-11-1**] Discharge Date: [**2176-11-5**]Date of Birth: Sex: MService:CHIEF COMPLAINT:
Respiratory failure
DISEASE
.HISTORY OF PRESENT ILLNESS: This is a 75 year old man withhistory of advanced
dementia
DISEASE
(
Alzheimer's type
DISEASE
) and type 2
diabetes mellitus
DISEASE
presenting to the Emergency Departmentwith
fever cough hypoxemia
DISEASE
. The patient was noted bycaregivers to be more lethargic than usual and with nasalcongestion on the night prior to admission. On the day ofadmission the patient was more lethargic Admission Date: [**2186-4-3**] Discharge Date: [**2186-4-17**]Date of Birth: [**2130-1-17**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:KeflexAttending:[**First Name3 (LF) 1505**]Chief Complaint:
aortic stenosis
DISEASE
Major Surgical or Invasive Procedure:[**2186-4-4**]Aortic Valve Replacement (23mm St. [**Male First Name (un) 923**] Epic Supra Porcine)left heart catheterization coronary angiogramright leg anterior compartment fasciotomy [**2186-4-10**]closure faciotomy [**2186-4-13**]History of Present Illness:This 65 year old gentleman has a history of a bicuspid aorticvalveassociated
aortic stenosis
DISEASE
and history of past aortic valve
endocarditis
DISEASE
. From a cardiac perspective he reports feelingwell. He
shortness of breath palpitations dizziness
DISEASE
lightheadedness PND orthopnea
DISEASE
or
lower extremity edema
DISEASE
. Hedoes note some mild
left chest heaviness
DISEASE
with exertion.Although he does not do any regular exercise his activities ofdaily living are without limitations. His most recentechocardiogram early this [**Month (only) 956**] showed severe
aortic stenosis
DISEASE
with increased gradients and mild
left ventricular hypertrophy
DISEASE
.Given the severity and progression of his disease he has beenreferred to Dr. [**Last Name (STitle) **] for surgical management.Past Medical History:
Aortic Stenosis
DISEASE
Bicuspid Aortic ValveHistory of
Endocarditis
DISEASE
HIV Positive(CD4 576 VL 104 - [**10/2185**])Chronic
Hepatitis C
DISEASE
- s/p Interferon treatment
Hepatitis A
DISEASE
& B
Dyslipidemia
DISEASE
Hypertension
DISEASE
Cervical Radiculopathy
Peripheral Neuropathy
DISEASE
History of ShinglesHistory of
Anemia
DISEASE
History of IritisHistory of
Colonic Polyps
DISEASE
- s/p Excision of left arm lipoma [**2184-8-22**]- s/p I and D of left arm abscess [**2185-11-22**]Social History:Lives with: HusbandContact: Phone #Occupation: Works as a pharmacy technicianCigarettes:
Smoked
DISEASE
no [X] yes [] last cigarette Admission Date: [**2174-2-12**] Discharge Date: [**2174-2-14**]Date of Birth: [**2122-4-28**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2474**]Chief Complaint:
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:51 yo M with h/o
asthma
DISEASE
and
right lung volume loss
DISEASE
of unclearetiology (Admission Date: [**2196-1-29**] Discharge Date: [**2196-2-3**]Date of Birth: [**2161-4-2**] Sex: MService: [**Company 191**]CHIEF COMPLAINT: Shortness of breath.HISTORY OF PRESENT ILLNESS: The patient is a 34 year old manwith history of
obstructive sleep apnea
DISEASE
and
hypertension
DISEASE
whopresented with sudden onset coughing fit and
syncope
DISEASE
and wasfound to have bilateral massive
pulmonary embolism
DISEASE
by CTangiogram. The patient had noted some
shortness of breath
DISEASE
and
pallor
DISEASE
with exercise starting in [**2195-4-2**]. During thesummer the patient noticed that he was short of breath afterclimbing stairs.In [**Month (only) **] the patient was diagnosed with question of lungdisease and given Albuterol. The patient's
dyspnea
DISEASE
progressed and he was started on Pulmicort with some responseon pulmonary function tests. A few days before presentationthe patient called his doctor [**First Name (Titles) 1023**] [**Last Name (Titles) 2875**] the patient witha Prednisone burst treatment without success. The patient wasat home and dyspneic with minimal activity. The patient hada chest CT on [**2196-1-29**]. It was noncontrast which was read asnormal.The day before presentation the patient had a coughing fitwith witnessed
syncope
DISEASE
. The patient denies any
hemoptysis
DISEASE
.He admitted to fifteen pound
weight loss
DISEASE
over the last fewmonths. The patient had been on a 24 hour nonstop trip to[**State 108**] since [**Month (only) **]. The patient denied any familyhistory of clots or personal history of clots. No recent
trauma
DISEASE
and no recent surgery.PAST MEDICAL HISTORY:1.
Hypertension
DISEASE
.2. Obstructive sleep
apnea
DISEASE
on CPAP.3. Tonsillectomy.4. Question of
asthma
DISEASE
.5. History of echocardiogram that revealed mild decreasedleft ventricular function.6. History of
dyspnea
DISEASE
on exertion since [**2195-4-2**].ALLERGIES: No known
drug allergies
DISEASE
.MEDICATIONS ON ADMISSION:1. Univasc.2. Prilosec.3. Prednisone.4. Multivitamin.SOCIAL HISTORY: The patient works as a computer networker.He is married with three children. The patient denies anytobacco or alcohol use.FAMILY HISTORY: Significant for
rheumatoid arthritis
DISEASE
and
leukemia
DISEASE
.PHYSICAL EXAMINATION: The patient had a blood pressure of115/70 with a pulse of 118. Respiratory rate was 20 withoxygen saturation of 100% on two liters. Generally thepatient was a fairly ill appearing man in no apparentdistress. Head eyes ears nose and throat examinationrevealed
extraocular movements
DISEASE
intact. The pupils are equalround and reactive to light and accommodation. On neckexamination
jugular venous distention
DISEASE
was approximately sixcentimeters of water. On cardiac examination the patientwas tachycardic with normal S1 and S2 and a III/VI blowingsystolic murmur at the left upper sternal border and leftlower sternal border. There were no lifts or
heaves
DISEASE
appreciated. Pulmonary examination revealed lungs that wereclear to auscultation bilaterally. Abdominal examinationrevealed the belly to be soft nontender nondistended withno
hepatosplenomegaly
DISEASE
. Rectal examination was negative.Extremity examination revealed no
edema
DISEASE
although there weredecreased pulses bilaterally.LABORATORY DATA: The patient had a white blood cell count of16.0 with a hematocrit of 44.5. The patient had a blood ureanitrogen of 18 and creatinine of 1.0. The patient's INR was1.2. The patient had initial CK of 134 CK MB of 7.0 andtroponin of less than 0.3.Chest x-ray was read as normal. Chest CT angiogram revealedbilateral pulmonary emboli that were extensive but withoutsaddle emboli. Lower extremity ultrasound revealed leftdistal superficial femoral to popliteal vein clot.HOSPITAL COURSE: The patient is a 34 year old with a historyof
obstructive sleep apnea
DISEASE
reversible
airway disease
DISEASE
onpulmonary function tests and
dyspnea
DISEASE
on exertion for sixmonths who presented with extensive bilateral pulmonaryemboli.1. Cardiovascular - The patient with extensive pulmonaryemboli with evidence of right ventricular dilatation andstrain on an echocardiogram. Because of the patient's stablehemodynamics he did not receive thrombolytics but was ratherstarted on Heparin infusion after a bolus. Workup ofhypercoagulable states were started in the Intensive CareUnit where the patient was admitted.The patient had protein C and S antithrombin III factor [**Initials (NamePattern4) **][**Last Name (NamePattern4) 5244**] prothrombin gene mutation 202-10 analysishomocysteine level
antiphospholipid
DISEASE
antibodyanticardiolipin antibody studies sent.The patient was provided with supplemental oxygen. He wasmaintained on therapeutic level Heparin. The patient wasstabilized and eventually transferred to the floor. He wasstarted on Coumadin 5 mg p.o. for the first day and then thiswas increased to Coumadin 7.5 mg p.o. for the next two days.The patient was monitored on telemetry. The patient hadoccasional episodes of
ventricular bigeminy
DISEASE
and premature
ventricular contractions
DISEASE
but otherwise remained in sinusrhythm. His homocysteine level returned within normallimits.On the day of discharge the patient had a therapeutic INR of2.6. He was discharged on Coumadin 5 mg p.o. q.d. with INRfollowed by his primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 4127**].2. Hematologic - The patient with decreased hematocrit from42.0 to 37.0 while in the Intensive Care Unit. He was guaiacnegative and this was thought to be secondary to dilution.His hematocrit remained stable throughout the rest of thehospital stay.3. Pulmonary - The patient with
obstructive sleep apnea
DISEASE
onCPAP. He was maintained on CPAP throughout thehospitalization and was gradually weaned off supplementaloxygen to the point where he was saturating 98% in room air.4. Gastrointestinal - The patient presented with history ofelevated liver function tests. The patient remained withelevated liver function tests throughout the hospitalization.His ALT was 112 on the day of discharge and AST was 62. Hewill likely need to have these followed up by his primarycare physician.CONDITION ON DISCHARGE: Excellent.DISCHARGE STATUS: The patient was discharged home.MEDICATIONS ON DISCHARGE:1. Coumadin 5 mg p.o. q.d.2. Protonix 40 mg p.o. q.d.The patient was advised to follow-up with his primary carephysician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 4127**] in one week. The patientwill have INR checked a location close to him with resultsfaxed to his primary care physician. [**Name10 (NameIs) **] patient will bereferred to the
hypercoagulation
DISEASE
clinic at [**Hospital1 346**]. He was advised to call to make anappointment at [**Telephone/Fax (1) 5245**].DISCHARGE DIAGNOSES:1. Extensive bilateral pulmonary emboli.2. Possible
hypercoagulable
DISEASE
state.3. Mild
hypertension
DISEASE
.4. Obstructive
sleep apnea
DISEASE
.5. Question of
asthma
DISEASE
. [**Name6 (MD) 251**] [**Name8 (MD) **] M.D. [**MD Number(1) 910**]Dictated By:[**Last Name (NamePattern1) 5246**]MEDQUIST36D: [**2196-2-3**] 12:59T: [**2196-2-9**] 12:55JOB#: [**Job Number 5247**]cc:[**Name8 (MD) 5248**]Admission Date: [**2176-12-11**] Discharge Date: [**2176-12-16**]Date of Birth: [**2121-12-5**] Sex: FService: MEDICINE
Allergies
DISEASE
:Lithium / Depakote / NeurontinAttending:[**First Name3 (LF) 759**]Chief Complaint:drug
overdose respiratory failure
DISEASE
Major Surgical or Invasive Procedure:placement of right IJHistory of Present Illness:55yo woman with
psychiatric
DISEASE
history and previous suicidal
ideation
DISEASE
presented to ED after being found unresponsive. Likely
overdose
DISEASE
on ativan seroquel and risperdol. On presentation tothe EDwas unresponsive and unstable [**Company 5249**] 104.8 148 16 88%
RA
DISEASE
. Glcwas 123.She was intubated and given charcoal as well as dantrolene forpotentialNMSAdmission Date: [**2160-10-8**] Discharge Date: [**2160-10-17**]Date of Birth: [**2086-8-16**] Sex: MService: NeurologyHISTORY OF PRESENT ILLNESS: The patient is a 74 year oldright handed man with a history of
hypertension
DISEASE
whopresented to the Emergency Room with acute right sidedweakness. The patient was in his usual state of health whenwitnessed by his family at 1:00 p.m. on [**2160-10-8**] whenEmergency Room where his vital signs were stable. He deniedcomplaints on arrival. He denied
chest pain
DISEASE
and
palpitations
DISEASE
. According to his daughter he has some chronic
shortness of breath
DISEASE
.PAST MEDICAL HISTORY: 1. Well controlled
hypertension
DISEASE
. 2.Benign
prostatic hypertrophy
DISEASE
. 3. Osteoarthritis. 4.Low B12.MEDICATIONS ON ADMISSION: Coreg 6.25 mg p.o.b.i.d. Diovan160/12.5 mg p.o.q.d. Tylenol #3 p.r.n. B12 i.m.q. monthunclear if patient started this yet Celebrex p.r.n.SOCIAL HISTORY: The patient is a Russian immigrant he isEnglish speaking. He is a retired artist. He drinks alcoholrarely and does not smoke.ALLERGIES: The patient has no known drug
allergies
DISEASE
.PHYSICAL EXAMINATION: On physical examination on admissionthe patient had a blood pressure of 160/100 respiratory rate14 pulse 60 and oxygen saturation 98% on three liters nasalcannula. Neck: No
carotid bruits
DISEASE
. Cardiovascular: Distantheart sounds no murmur. Abdomen: Soft nontender. Lungs:Clear to auscultation bilaterally. Neurologic examination:Alert and oriented
speech nonfluent
DISEASE
with paraphrasic errorsRussian accent but speaking in English following commandsrepetition mildly impaired severe
anomia
DISEASE
perseverated withthe word Admission Date: [**2150-12-13**] Discharge Date: [**2150-12-19**]Service: MEDICINE
Allergies
DISEASE
:Opioid AnalgesicsAttending:[**Last Name (NamePattern1) 1167**]Chief Complaint:
Chest pain
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:83 yo F with known CAD s/p MI baseline
LBBB
DISEASE
who presented with
chest pain
DISEASE
back
pain
DISEASE
starting at 10:45 am. Admission Date: [**2110-9-2**] Discharge Date: [**2110-9-5**]Service: UROLOGY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 5272**]Chief Complaint:
hematuria
DISEASE
Major Surgical or Invasive Procedure:S/p cystoscopy clot evacuation of bladder [**2110-9-2**]History of Present Illness:Mr. [**Known lastname 349**] is a healthy [**Age over 90 **]yo M with
hypertension
DISEASE
hyperlipidemia
DISEASE
and
type II diabetes
DISEASE
who developed the acuteonset of pressure both when needing to urinate and when tryingto hold his urine in on the morning of [**2110-9-1**]. He denies any
fevers chills
DISEASE
night
sweats nausea
DISEASE
or
back pain
DISEASE
. He statesthat he was eventually able to urinate but that it took a lot ofeffort. Later that morning he also developed
hematuria
DISEASE
andclots in his urine. This was not associated with
pain
DISEASE
on
urination
DISEASE
but he did have the continued sensation of pressure.He called Dr. [**Last Name (STitle) 770**] who advised him to go the ER forevaluation. Of note he had undergone a urologic evaluation lastThursday for a urine cytology which was reported as Admission Date: [**2174-9-28**] Discharge Date: [**2174-10-3**]Date of Birth: [**2097-4-19**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1145**]Chief Complaint:
Pericardial effusion atrial fibrillation
DISEASE
with RVR.Major Surgical or Invasive Procedure:None.History of Present Illness:Mr. [**Known lastname 1924**] is a 77-year old male with minimal prior medical carefor over 50 years with no known past medical problems who wasbrought to the [**Name (NI) **] this morning by his social worker because hewas noted to have
labored
DISEASE
breathing. He minimizes his symptomsand reports that he has been feeling Admission Date: [**2105-2-25**] Discharge Date: [**2105-2-28**]Service: MEDICINE
Allergies
DISEASE
:Xanax / Vicodin / darvocetAttending:[**First Name3 (LF) 602**]Chief Complaint:
Respiratory failure
DISEASE
Major Surgical or Invasive Procedure:Mechanical intubation and ventilation.History of Present Illness:87 yof with history of
atrial fibrillation
DISEASE
on coumadin withrecent total shoulder arthroplasty secondary to
OA
DISEASE
who presentsin
respiratory failure
DISEASE
. History is obtained from the son whoreports that he was with her until 8pm tonight at which pointshe felt well without
complaint
DISEASE
. Around 11pm he received a callfrom her complaining of SOB. He notes that she has had anon-productive
cough
DISEASE
for the past few days but no shortness ofbreath until tonight. She was not complaining of
chest pain
DISEASE
orany other symptoms. He arrived at her house and reports hearinga gugurling sound while she breathed. EMS was called and pt's
respiratory distress
DISEASE
progressed requiring intubation in thefield..Upon arrival to the ED CXR was obtained consistent with
pulmonary edema
DISEASE
. EKG was vpaced and unable to be interpreted for
ischemia
DISEASE
. She was sedated with fent/versed/propofol and ventsetting on transfer to the MICU were AC TV: 450 P: 18 peep 13100% fiO2. Her tox screen positive for benzos and tylenol. INRwas elevated at 5.2. Hct was 33.6 down from 36.8 on [**2104-12-22**]. Pttriggered for
hypotension
DISEASE
and propfol drip was held and shereceived 2L of NS. This was followed by a dose of 40mg IV lasix.On arrival to the MICU VS were: T 97.8 BP 175/75 HR 65 O2 100%on the above settings..Review of systems: Unable to obtain as she is intubated.Past Medical History:Atypical
chest pain
DISEASE
paroxysmal
Supraventricular Tachycardia
DISEASE
(
SVT
DISEASE
):- per review of OMR there was concern that she may have AVNRTalthough brief episodes of
AFib
DISEASE
noted on interrogation of PPMMobitz Type 2 2nd Degree
AV block
DISEASE
[**9-/2101**] s/p PPMdCHF mild
MR
DISEASE
Hypertension
DISEASE
Chronic back pain
DISEASE
Peptic ulcer disease
DISEASE
Anemia
DISEASE
with baseline Hct 31-34
Glaucoma
DISEASE
Osteoporosis
DISEASE
Osteoarthritis
DISEASE
Rotator cuff tearsAdmission Date: [**2145-11-24**] Discharge Date: [**2145-11-30**]Date of Birth: [**2085-4-13**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1505**]Chief Complaint:
Chest pain
DISEASE
Major Surgical or Invasive Procedure:Coronary artery bypass graft x3 (LIMA-Admission Date: [**2106-6-10**] Discharge Date: [**2106-6-17**]Date of Birth: [**2032-5-3**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:Aspirin / Penicillins / Sulfa (Sulfonamides) / Latex / KeflexAttending:[**First Name3 (LF) 1267**]Chief Complaint:
Chest Pain
DISEASE
Major Surgical or Invasive Procedure:Aortic Valve Replacement (19mm Mosaic Poricine) [**2106-6-10**]History of Present Illness:74 y/o female with known Aortic Stenosis who presented to EDwith
chest pain
DISEASE
intermittently x 2 weeks. Repeat Echo revealedworsening AS.
Referred
DISEASE
for elective valve surgery.Past Medical History:
Aortic Stenosis Hypertension Hypercholesterolemia
DISEASE
Hypothyroidism
DISEASE
Asthma Peripheral Vascular/Carotid DiseaseMeneire's Disease
Osteoarthritis
DISEASE
s/p bilat.
cataract
DISEASE
surgerys/p
hysterectomy s/p bladder suspension s/p hemerrhoidectomy
s/p cholecystectomy s/p appendectomy s/p hand
DISEASE
surgerySocial History:Patient is married and lives at home.
Denies
DISEASE
any history ofsmoking EtOH or recreational drug use.Family History:Non contributoryPhysical Exam:VS: Afebrile p-70's BP 126/54General: NAD WD/WNHEENT: Sclera nonicteric EOMI PERRLNeck: Supple -JVD Admission Date: [**2106-6-10**] Discharge Date: [**2106-6-17**]Date of Birth: [**2032-5-3**] Sex: FService: CSUADDENDUM: While Ms. [**Known lastname **] did have some changes in hermental status perioperatively there was no evidence either byradiographic imaging or physical examination that shesuffered a perioperative
stroke
DISEASE
. Her change in mental statuswas most likely related to
pain
DISEASE
medication. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**] [**MD Number(1) 1715**]Dictated By:[**Last Name (NamePattern1) 5297**]MEDQUIST36D: [**2106-7-26**] 07:04:33T: [**2106-7-26**] 09:00:10Job#: [**Job Number 5298**]Admission Date: [**2145-11-30**] Discharge Date: [**2145-12-1**]Date of Birth: [**2091-4-13**] Sex: MService: MEDICINE
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 2485**]Chief Complaint:
Afib
DISEASE
with RVRMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:54M with hx of ETOH abuse HCV presented to the ED this eveningintoxicated. Upon arrival the pt was noted to have
slurred
DISEASE
speech and decreased responsiveness. The patient states thattoday he invited a friend over to his house where he shared 1Lof vodka. The pt reports that while drinking he experienced leftsided
chest pain
DISEASE
that led his friend to call EMS for him. The ptstates he drinks heavily [**2-3**]/month. He denies history of
seizure
DISEASE
loss of urine or stool. No
loss of consciousness
DISEASE
noknown
trauma
DISEASE
. The pt describes his
chest pain
DISEASE
as left sided[**8-12**] with radiation to the left arm. No known CAD.Admission Date: [**2192-11-24**] Discharge Date: [**2192-12-7**]Date of Birth: [**2110-10-24**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:NitroglycerinAttending:[**First Name3 (LF) 922**]Chief Complaint:
syncope
DISEASE
Major Surgical or Invasive Procedure:[**2192-11-28**] aortic valve replacement (23 mm CE pericardial)/coronary artery bypass graft(SVG-RCA)/ ligation left atrialapppendage/MazeHistory of Present Illness:This 82 year old Russian speaking female with known critical
aortic stenosis
DISEASE
was admitted after a
syncopal
DISEASE
episode todaywhile at a museum. She was with her daughter and family friendshe felt slightly dizzy and then had episode of loss ofconsciousness where she fell into the arms of the family. Therewas no
trauma
DISEASE
or
head injury
DISEASE
. The physician family friendthought the patient was
pulseless
DISEASE
so she initiated CPR but thept regained a pulse and consciousness within Admission Date: [**2180-2-2**] Discharge Date: [**2180-2-5**]Date of Birth: [**2106-8-15**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Doctor First Name 1402**]Chief Complaint:transfer from cath lab for
acute pulmonary edema
DISEASE
s/p cathMajor Surgical or Invasive Procedure:Cardiac Catheterization with Drug Eluting Stent Placement.History of Present Illness:73 yo male with past medical history significant for CAD s/pCABG
insulin-dependent diabetes mellitus hypertension
DISEASE
hypercholesterolemia
DISEASE
and
peripheral vascular disease
DISEASE
PVD wasadmitted to [**Hospital1 18**] from [**Hospital3 3583**] with after having had[**6-23**] substernal
chest pain
DISEASE
. Patient was initially admitted to[**Hospital3 3583**] on [**2180-1-30**] with a
COPD
DISEASE
exacerbation and a rightlower lobe
pneumonia
DISEASE
being treated with IV antibioticssteroids and nebulizer treatment. On [**2180-2-1**] patientexperienced [**6-23**] substernal
chest pain
DISEASE
with associated bilateralarm
numbness
DISEASE
and troponin I of 11. He initially receivedmorphine and ativan without relief and then received 5mg IVmetoprolol and IV nitroglycerine with relief. On 12.20 patientfound to have troponin I with 83.41 and was transferred to [**Hospital1 18**]for cardiac catheterization..At cardiac cath patient found to have the following: 3 vesselnative coronary artery diseaseAdmission Date: [**2181-10-5**] Discharge Date: [**2181-10-13**]Date of Birth: [**2106-8-15**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 458**]Chief Complaint:
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:IntubationHistory of Present Illness:Mr. [**Known lastname 5314**] is a 75 yo male with h/o
CHF
DISEASE
and CAD s/p CABG whopresented to presented on [**10-4**] to [**Hospital3 3583**] with a
complaint
DISEASE
of
chest pain
DISEASE
and
shortness of breath
DISEASE
. Patient isintubated at time of transfer to [**Hospital1 18**] and history was obtainedalmost entirely from discharge summary..At time of admission to [**Hospital3 3583**] he described suddenonset of sharp left-sided
chest pain
DISEASE
with onset at rest. Onarrival to the ED he reported shortness of breat and was foundto have SpO2 84% on room air. He was placed on a nonrebreatherand was subsequently intubated in the ED for respiratoryfailure. The patient was treated with lasix and responded withgood UOP and improvement of his respiratory status. ABGperformed 90 minutes after intubation was 7.18/72/86..Mr. [**Known lastname 5314**] was subseqnetly admitted to the CCC at [**Hospital1 3325**] where he was started on standing IV lasix Nitro paste1Admission Date: [**2127-3-9**] Discharge Date: [**2127-3-14**]Date of Birth: [**2054-11-23**] Sex: FService: MEDICINE
Allergies
DISEASE
:PenicillinsAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:Altered Mental
Status hypotension
DISEASE
Major Surgical or Invasive Procedure:CVL placementHistory of Present Illness:Ms. [**Known lastname 5320**] is a 72 y/o female with a history of HCV metastatic
HCC
DISEASE
that is not amenable to treatment who initially presentedto the ER with altered mental status since last night. Herdaughters say that starting yesterday she was much more sleepynot wanting to get up they also said that she had been coughingand having
nasal congestion
DISEASE
. She was not eating or drinkingmuch only a few small sips of water. This morning she was notreally waking up much so they called 911. A BLS ambulancearrived and her fingerstick was 27 they attempted to give heroral glucose while awaiting an ACLS ambulance after the oralglucose her repeat blood sugar was 17. After the ACLS ambulancearrived she was given 1 amp of D50 and brought her into the[**Hospital1 18**] ER.In the ED initial VS were: 97 83/41 22. She was given 2LNSbut remained
hypotensive
DISEASE
so a right IJ was placed and she wasstarted on levophed. A bedside ultrasound was done that showed asmall amount of
ascites
DISEASE
a paracentesis was attempted twice butfailed a CXR was concerning for possible
pneumonia
DISEASE
so she wasgiven vancomycin ceftriaxone and flagyl. Labs were notable fora WBC of 2.1 with 25bands lactate of 6.7 INR of 2.6 U/A with19 white cells Cr of 2.5 from a baseline of 1.0. VS ontransfer: 124/97 on 0.03 of levo 77 22 95-100% on
RA
DISEASE
..On arrival to the MICU her initial VS: 98.8 118 124/64 2094% on 3LNC. Using her daughters to translate she denied any
pain chest pain shortness of breath nausea/vomiting
DISEASE
or
abdominal pain
DISEASE
..Review of systems:(Admission Date: [**2163-10-6**] Discharge Date: [**2163-10-13**]Date of Birth: [**2086-4-12**] Sex: FService: ORTHOPAEDICS
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 64**]Chief Complaint:left hip
pain
DISEASE
[**2-14**] protusion failed left THRMajor Surgical or Invasive Procedure:left revision THRHistory of Present Illness:Patient is a 77F who had a primary left total hip replacement in[**2152**] by another surgeon that sustained progressive protrusioearly ultimately failing with loss of fixation of theacetabulum. I brought [**Known firstname 5321**] to surgery a little over a year agoat which time we felt that her best treatment optionintraoperatively would be allograft packing of the acetabulumdefect and ahemiarthroplasty head. Also considered at the time was aRestoration GAP prosthesis. She did well for probably 10 or 12months and then started developing
pain
DISEASE
and x-rays demonstratedprogressive protrusio with the femoral head at risk for pushingthrough the remnant of the acetabulum. We have also seeninsufficiency
fractures
DISEASE
developing on the pubic ramus and in theposterior wall of the acetabulum. The patient is developingprogressive
pain
DISEASE
unrelenting and sciatic symptoms. She hasbeen made nonweightbearing a couplemonths ago in preparation for the surgery. She understands thisis very much a salvage operation. She is developing progressivefracturing from
osteoporosis
DISEASE
and there is very little bone stockremaining. She is really not a candidatefor major allograft pelvic reconstruction as fixation would belimited. Best treatment course cemented GAP cage and avoidanceof further allograft.Past Medical History:history lymphoma in [**2160**] history of
ovarian cancer
DISEASE
splenectomy[**2160**] for lymphomaAdmission Date: [**2164-5-3**] Discharge Date: [**2164-6-12**]Date of Birth: [**2086-4-12**] Sex: FService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 3223**]Chief Complaint:
Left leg pain
DISEASE
& malaiseMajor Surgical or Invasive Procedure:[**2164-5-4**] R-Admission Date: [**2164-6-24**] Discharge Date: [**2164-7-20**]Date of Birth: [**2086-4-12**] Sex: FService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 3223**]Chief Complaint:persistent
anemia
DISEASE
bloody ostomy
output leukocytosis
DISEASE
Major Surgical or Invasive Procedure:[**2164-6-28**]: PEG placement[**2164-7-1**]: Decompression of
septic left pelvic hematoma
DISEASE
irrigation and debridement via arthrotomy down to theacetabular space cultures and placement of vacuum sponge.[**2164-7-1**]: Re-exploration of
left thigh bleeding
DISEASE
.[**2164-7-5**]: Serial irrigation and debridements of left hipAdmission Date: [**2125-4-29**] Discharge Date: [**2125-5-29**]Date of Birth: [**2053-11-6**] Sex: FService: MEDICINE
Allergies
DISEASE
:VancomycinAttending:[**First Name3 (LF) 45**]Chief Complaint:Rib
pain
DISEASE
Major Surgical or Invasive Procedure:IntubationStress MIBIHistory of Present Illness:71 y/o F w/ metastatic breast ca w/ bone involvement ontamoxifen who presents with worsening right rib
pain
DISEASE
..She reports that rib
pain
DISEASE
has been a chronic problem but hasbeen worse over past one week. The right side is worse but shealso reports left sided rib
pain
DISEASE
and
chest wall pain
DISEASE
. She doesnot report any
trauma
DISEASE
or heavy lifting or turning that seemed toprecipitate the
pains
DISEASE
. She was recently started on percocet for
pain
DISEASE
which did help but she has had to take it around the clockwithout full relief..ROS: denies n/v/f/c. no
chest pain
DISEASE
. Admission Date: [**2121-8-20**] Discharge Date: [**2121-8-28**]Date of Birth: [**2050-2-24**] Sex: FService: MEDICINE
Allergies
DISEASE
:Morphine / Aspirin / Methocarbamol / Meperidine / HydrocodoneAttending:[**First Name3 (LF) 2751**]Chief Complaint:
Dyspnea
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:71F with PMH of
CHF AAA
DISEASE
and
chronic back pain
DISEASE
presenting fromRehab with
confusion
DISEASE
and
disorientation
DISEASE
found to have a TAdmission Date: [**2148-3-2**] Discharge Date: [**2148-3-7**]Date of Birth: [**2070-10-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:
Hypotension/hypoxia
DISEASE
Major Surgical or Invasive Procedure:Placement of Dobhoff tubePlacement of Arterial lineHistory of Present Illness:77 yo M NH resident h/o
schizophrenia
DISEASE
CAD
HTN dementia
DISEASE
p/w
hypoxia
DISEASE
and FTT from NH. According to the NH records pt had anepisode of
desaturation
DISEASE
to mid 80's on
RA
DISEASE
several days ago. Hecame up to 91% on 2L NC. He was also noted to have decreased pointake eating only with assistance and only preferred foods.IVF fluids were given. CXR at NH neg UA pos. Started onlevaquin 500 mg po on [**2-29**] also given 1 dose of CTX.Subsequently ucx came back as Admission Date: [**2194-5-8**] Discharge Date: [**2194-5-14**]Service: MEDICINE
Allergies
DISEASE
:Lisinopril / Nsaids / NesiritideAttending:[**First Name3 (LF) 1865**]Chief Complaint:
Shortness of breath
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:* interview conducted with the aid of Ms. [**Known lastname 1862**] daughter.History of Present Illness: Ms. [**Known lastname **] is an 86 y/o F withhistory of
nephrotic
DISEASE
CRI
renal artery stenosis
DISEASE
and
CHF
DISEASE
whopresented with
hypertensive
DISEASE
emergency and
heart failure
DISEASE
. Thepatient reports that she was in her usual state of health until3 days prior to admission. At that time her BP was 220 systolicAdmission Date: [**2148-3-20**] Discharge Date: [**2148-3-29**]Date of Birth: [**2070-10-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 783**]Chief Complaint:HypoxiaMajor Surgical or Invasive Procedure:CVL placementIntubationJ-tube placementHistory of Present Illness:Mr. [**Known lastname 5345**] is a 77 year-old male with a history of CAD s/pCABG
HTN schizophrenia
DISEASE
recent admission forhypoxia/hypotension with unknown etiology who presents fromrehab with
hypoxia
DISEASE
to 78 on
RA
DISEASE
- 88 on NC. His PCP at [**Name9 (PRE) 5346**] started him on cefepime 1g IV bid for one week starting on[**3-14**] for a positive UA in setting of elevated white count.According to her she sent three C diff samples that werenegative and had given him empiric flagyl for three days in theinterim..He was sent to the ER where he was found to be 92-96 on NRBmask. His BP ranged from 90s-120s. He was intubated for
hypoxia
DISEASE
(etomidate and succinylcholine given). CXR was performed and hewas given levoflox and ctx x 1. OGT was placed. Thick yellowsputum was suctioned from his ETT. He recieved 3L NS. Troponinreturned at 0.13 with flat CK and his EKG (Qs in V1-4 but nochange from prior) was faxed to cardiology who did not suspectacute MI and recommended he be given aspirin only (he was givenASA 325 mg po x 1). His WBC was 25.6 with 92% PMNs and no bands.UA was negative. Lactate was 1.7. Electrolytes were normal..Of note he was recently hospitalized [**Date range (1) 5347**] in the ICU afterbeing admitted for desat to 80s
hypotension
DISEASE
. He was started onempiric antibiotics at that time for possible aspiration pnahowever all culture data and imaging was negative and wasstopped. Imaging of his L ankle
decubitus ulcer
DISEASE
did not show
osteomyelitis
DISEASE
. He was also worked up for AMS with head CT andneuro c/s. Neuro felt he may have had a small
TIA
DISEASE
with R sided
weakness
DISEASE
and transient R sided facial droop. He was continuedon aspirin an increased dose of statin and Plavix. His
neurological symptoms
DISEASE
had resolved at the time of discharge. Hewas fed through an NGT however when he was discharged to his NHthis was pulled and he continued to have poor nutritionalintake which is not ideal especially given his chronicdecubitus
ulcers
DISEASE
(5 of them). He has an appointment for PEGplacement on [**3-22**] for poor nutritional status. Echo during hislast hospitalization showed EF 35% and EKG and CEs wereconsistent with likely MI prior to admission (trop 0.14). He wasadmitted to the MICU for further care..ROS: Unable to assess given pt sedated intubatedPast Medical History:Recent hospitalization for
hypoxia hypotension
DISEASE
of unknownetiology
TIA
DISEASE
in [**3-5**]
Schizophrenia
DISEASE
per PCP [**Name Initial (NameIs) 5348**] AAOx1 verbally abusive
Depression
DISEASE
HTN
DISEASE
Dementia
DISEASE
R eye
cataract
DISEASE
CAD s/p CABGSocial History:Eats a pureed diet. Mostly bedbound at [**Name Initial (NameIs) 5348**]. Pt has nofamily. Has legal guardian [**Name (NI) 3608**] [**Name (NI) 4334**]. Per discussion withPCP [**Name10 (NameIs) 3608**] is not comfortable making code decision for pt sothere was a court date on [**3-19**] to appoint a guardian ad [**Name2 (NI) 5349**]for the purposes of making code decision for pt. This person hasyet to be appointed.Family History:Non-contributoryPhysical Exam:Vitals: T: 97.9 BP: 116/64 HR: 88 RR: 18-20 O2Sat: 100% onAC 500*14 RR 16 FiO2 0.5GEN: opens eyes to name does not withdraw to
pain
DISEASE
sedatedintubated.HEENT: R eye surgical pupil bilat pupils small L eye sluggishresponse.COR: RRR no M/G/R normal S1 S2PULM: Lungs CTAB decreased at bases bilatABD: Soft NT ND diminished BS no HSMEXT: No C/C/E 1Admission Date: [**2148-4-8**] Discharge Date: [**2148-4-8**]Date of Birth: [**2070-10-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Last Name (NamePattern1) 495**]Chief Complaint:
hypoxia
DISEASE
s/p
PEA arrest
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:77 male nursing home resident 2 admissions in past month sentto the ED from his NH with
hypoxia
DISEASE
and worsening L sided PNA.He was found to have an O2 sat in the 70's while receiving 100%oxygen by non-rebreather face mask. He had some ectopy forwhich he received 75 mg of amiodraone. He was intubated and hisoxygen saturations remained low in the 60's with PAO2 in the40's on vent settings of AC 500 x 15 10 peep. His CXR showedworsened PNA with white out of the L lung and his labs returnedwith Admission Date: [**2110-9-15**] Discharge Date: [**2110-10-23**]Date of Birth: [**2060-1-1**] Sex: MService: MEDICINE
Allergies
DISEASE
:IbuprofenAttending:[**First Name3 (LF) 465**]Chief Complaint:
lethargy
DISEASE
Major Surgical or Invasive Procedure:intubation x2colonoscopyEGDright femoral lineleft sunclavian line
left cordis
DISEASE
with Swanarterial lineHistory of Present Illness:The pt is a 50yo M with PMHx significant for
alcohol abuse
DISEASE
andCAD with multiple MI's prior MI [**2105**] with OM stent and PCI at[**Hospital1 18**] [**2109-4-20**] of the proximal RCA and mid-RCA (both Taxus)LAD stent at [**Hospital1 112**] in [**2105**]. The patient initially was in the[**Hospital 5353**] Hospital ED on [**9-8**] with
chest pain
DISEASE
. EKG showed NSRnonspecific ST-T changes per report. The paitent left AMA beforefurther w/u was done. He then presented to [**Hospital3 **] viaEMS on [**9-15**] with increase lethergy and
jaundice
DISEASE
for the lastthree days. He was transfeed to [**Hospital1 18**] ED for a
GIB
DISEASE
and a HCT of21. He was transfused before transfer with 1 unit..From the medicine admission note:Pt states he has never had
liver problems
DISEASE
or h/o
jaundice
DISEASE
buthas taken about 14 tylenol over past week for
chronic back pain
DISEASE
.Pt reports he was on an alcohol binge while in [**Location (un) 5354**] oneweek ago. Around the time he came back he developed
chest pain
DISEASE
and was seen in the [**Hospital3 **] ED where
chest pain
DISEASE
resolvedwith NG and he was discharged. Pt is very unclear about this -states that he had an MI but was only given SL NG and wasdischarged without admission. [**Hospital3 **] was contact[**Name (NI) **] andthey currently have no record of EKGs or other recordsindicating that pt was seen one week ago - at last communicationwith RN in ED of [**Hospital1 **] it was felt that perphaps visit had notyet been logged in to computer and will need to contact againtomorrow. Since that time he developed
melena
DISEASE
and
jaundice
DISEASE
. Hedenies
dizziness
DISEASE
or
chest pain
DISEASE
but in the [**Hospital3 **] ED hewas found to have elevated LFTs Hct of 22 received 1u PRBC andtransferred to [**Hospital1 18**]. Here pt refused EGD and NG lavage. In[**Hospital1 18**] ED received 2u PRBC octreotide and PPIs as well as KCLfor
hypokalemia
DISEASE
N-acetylcysteine for elevated tylenol levelsand antibiotics for
bandemia
DISEASE
.
RUQ showed gall baldder sludge
DISEASE
butno bilary dilation. He was felt to have no
ascites
DISEASE
and so wasnot tapped. After receiving the two units of PRBC he desaturatedto from 96% to 88% on
RA
DISEASE
. Received Lasix for
volume overload
DISEASE
.The paitent was then admitted to a medicine team via NF. Herecieved a total of 3 transfusions here and his and his HCT hasonly gone up from 22.6 to 25.2. Also he has having multipleepisodes of melana. He went for an EGD today ([**9-16**]) but was notcoorperative despite midazloam 3mg and meperidene 75mg. He alsostarted to have
hallucinations
DISEASE
on the floor. Therefore he wastx to the MICU for closer monitoring and intubation for EGD...ROS: denies CP SOP abd
pain
DISEASE
. Per wife he always hs
wheezing
DISEASE
not dx with a lung condition. He has been having increasing
swelling
DISEASE
in his left lower leg for the past 6 months.Past Medical History:-alcohol abuse - pt reports that he drinks 2-3 beers per daydenies DTs. no prior history of
liver disease
DISEASE
-CAD s/p MI [**2105**] stent LAD [**2107**] stent mid and prox RCA in [**2108**]- Per wife in [**2082**] the patient had a motorcycle accident andbroke his femur and had
compartment syndrome
DISEASE
leading to afasicotomy in the right lower leg. He has had multiple
DVT
DISEASE
'ssince in that leg.-
herniated lumbar disc
DISEASE
with
sciatica
DISEASE
on
chronic pain
DISEASE
medicationsSocial History:90 tobacco pack yr history lives alone drinks beer and liquor[**1-24**] drinks per day on diasbilty for the last 10 yearsPer the patient's wife: The patient has a h/o a sucide attemptby cutting his wrists 5 years ago. She dose not know of anyinpatient ETOH detox stays DTs or
seizures
DISEASE
. The patient hasbeen living alone for the last 6 months becaue she could nottolerate his drinking. recently he has switched to vodka.Family History:multiple MI'sPhysical Exam:T 99.7 P 90 BP: 112/72 RR 20Admission Date: [**2173-9-3**] Discharge Date: [**2173-9-22**]Service: MEDICINE
Allergies
DISEASE
:Sulfa (Sulfonamides)Attending:[**First Name3 (LF) 2387**]Chief Complaint:Cold footMajor Surgical or Invasive Procedure:Angiography/stent left Superficial Femoral ArteryHistory of Present Illness:86 y/o male with a hx of 3V CAD
CHF
DISEASE
- EF 35% chronic afibDM2
PVD
DISEASE
s/p bypass L [**Doctor Last Name **]--Admission Date: [**2119-4-13**] Discharge Date: [**2119-4-18**]Date of Birth: [**2084-2-7**] Sex: FService: NEUROSURGERY
Allergies
DISEASE
:Latex / Erythromycin Base / Percocet / Vicodin / Sulfa(Sulfonamides) / Penicillins / Alcohol / EggAttending:[**First Name3 (LF) 1835**]Chief Complaint:35F with 6 months of
headaches
DISEASE
and
intermittent dizziness
DISEASE
whowas found to have a 2.4cm left cerebellar brain massMajor Surgical or Invasive Procedure:[**2119-4-13**]:Left suboccipital craniotomy for
tumor
DISEASE
resection withcranioplastyHistory of Present Illness:35 year old female presents with approximately 6 months of
headaches
DISEASE
and
intermittent dizziness
DISEASE
. She reports no visualchanges no new gait disturbances no
numbness
DISEASE
or tingling. HerPCP referred her to Dr. [**Last Name (STitle) **] who ordered an MRI of the brain.She had this in [**2119-1-10**] and the study revealed a brainmass in the left cerebellum measuring 2.4 cm at the greatestdiameter. Dr. [**Last Name (STitle) **] then referred her to Dr. [**Last Name (STitle) **] forneurosurgicalconsultation.Past Medical History:
sarcoidosis
DISEASE
(affecting
liver and kidneys) - dx
DISEASE
in [**2115**]multiple
ear infections
DISEASE
s/p multiple surgeries s/p lymph nodebiopsy s/p kidney biopsy s/p cyst removal
HTN
DISEASE
(secondary to
sarcoidosis
DISEASE
in kidneys)
hypercholesterolemia
DISEASE
Social History:lives alone works as Nanny part timeFamily History:mother:died from metastatic breast CA maternalgrandmother and [**Name2 (NI) 5358**] aunt both had non-[**Name (NI) 4278**]
Lymphoma
DISEASE
maternal grandfather had
leukemia
DISEASE
Physical Exam:On Discharge:Neurologically intact. Scalp incision clean
dry
DISEASE
intact.
Rash
DISEASE
to FA significantly improved with only trace red pigmentationand non-pruritic.Pertinent Results:Labs on Admission:[**2119-4-13**] 01:59PM BLOOD Hct-34.9*[**2119-4-14**] 01:26AM BLOOD Plt Ct-311------------------IMAGING:-----------------NCHCT [**4-13**](post-op): stable with expected post-operativechanges.MRI Head [**4-14**](post-op): Expected postsurgical changes identifiedat the left posterior fossa status post
meningioma
DISEASE
resection asdescribed. There is no evidence of
intracranial hemorrhage
DISEASE
orischemic changes. The previously noted
meningioma
DISEASE
at the leftposterior fossa has been resected with no evidence of residualmass followup after complete reabsorption of the post-surgicalblood products is recommendedBrief Hospital Course:Patient presented electively for resection of left posteriorfossa mass on [**2119-4-13**] and underwent left suboccipital craniotomyfor resection of mass with cranioplasty without complications.Preliminary pathology in the OR showed that the mass was amenigioma. She was extubated in the OR and transferred to theICU post-op. Upon her post-op check she was found to be fullstrength with PERRL EOM's intact no drift and no dysmetria.On POD#1 her examination was stable so she was transferred tothe neurosurgery floor following her routine post-operative MRI.Her steroids were ordered to taper to off over four days.She was seen and evaluated by PT and OT who determined that shewas safe to go home without services. The patient developed a
rash
DISEASE
on the left forearm which was initially thought to be
cellulitis
DISEASE
or an
allergic reaction
DISEASE
. She was placed onclindamycin for a couple of days. The
rash
DISEASE
was
pruritic
DISEASE
innature and improved greatly with benadryl. Therefore theClindamycin was discontinued. The
rash
DISEASE
subsequently improvedThe patient continued to have
pain
DISEASE
that was [**6-19**] on [**4-17**] so her
pain
DISEASE
regimen was adjusted accordingly. She responded well andwas discharged to home in good condition on [**2119-4-18**]. of notethe
rash
DISEASE
to her L FA was very faint and no longer pruritic atthe time of discharge.Medications on Admission:CeleXA 20mg'Jolessa 0.15mg/30mcg'Valsartan 160mg' Lorazepamprn spasmDiazepam 5mgAdmission Date: [**2107-7-10**] Discharge Date: [**2107-7-26**]Service:ADMITTING DIAGNOSIS: Status post
cardiac arrest
DISEASE
HISTORY OF PRESENT ILLNESS: This is an 89 year old womanwith a history of
atrial fibrillation
DISEASE
pulmonary
hypertension gastrointestinal bleed
DISEASE
with
chronic anemia
DISEASE
chronic renal insufficiency
DISEASE
who had been complaining at homeof lower
back pain
DISEASE
. On the morning of admission her daughterwas helping her to the bathroom when the patient collapsedwithout breathing without pulse. Daughter and [**Name2 (NI) 802**]initiated cardiopulmonary resuscitation and Emergency MedicalServices were called. Emergency Medical Services arrived andplaced an automated external defibrillator which determined a
shockable
DISEASE
rhythm. She received one
shock
DISEASE
of 200 joules whichconverted her to a
pulseless
DISEASE
electrical activity rhythm. Shewas given Atropine and a second
shock
DISEASE
and went into an atrial
fibrillation
DISEASE
rhythm with a rapid ventricular response. Thepatient was started on Lidocaine drip and was transferred tothe [**Hospital6 256**] Emergency Room.Total time
pulseless
DISEASE
was approximately 15 minutes. Thepatient arrived to the Emergency Room in rapid atrial
fibrillation
DISEASE
with a blood pressure in the 80s and was startedon intravenous fluids. Initial electrocardiograms showed nosignificant ST or T wave changes. Her first CK was 48 hercomponent was 2.7 her potassium was 2.5. At this time it isfelt likely that she had suffered a primary
arrhythmia
DISEASE
leading to her arrest. The patient was not taken to theCatheterization Laboratory but was admitted to the CoronaryCare Unit for further management.PAST MEDICAL HISTORY:
Atrial fibrillation
DISEASE
for which she ison Amiodarone. She has a history of a congestive heartfailure with an echocardiogram in [**2107-1-31**] showingconcentric left ventricular hypertrophy with an ejectionfraction of 50%. She had
biatrial enlargement
DISEASE
moderate
mitral regurgitation
DISEASE
and severe
pulmonary hypertension
DISEASE
. Shealso had a history of chronic
anemia
DISEASE
. She has a history of a
gastrointestinal bleed
DISEASE
in [**2107-3-31**] which was felt to bedue to a
gastric arteriovenous malformation
DISEASE
. She also haschronic
thrombocytopenia
DISEASE
with a baseline platelet count ofabout 80000. She also has
chronic renal insufficiency
DISEASE
. Herbaseline creatinine is approximately 1.4.MEDICATIONS AT HOME:1. Aspirin 81 mg q.d.2. Toprol XL 25 mg q.d.3. Zestril 40 mg q.d.4. Prilosec 20 mg q.d.5. Multivitamin one tablet q.d.6. Amiodarone 200 mg q. daySOCIAL HISTORY: She lives with her family she has ahomemaker. She walk with a cane. She does not have ahistory of tobacco and she occasionally uses alcohol.ALLERGIES: No known
drug allergies
DISEASE
.PHYSICAL EXAMINATION: On admission her vital signs weretemperature of 98.6 heartrate 109 blood pressure 130/78breathing 24 times per minute. She was vented on assistcontrol 500 cc by 12 with 60% FIO2 and positiveend-expiratory pressure of 5. Initial examination was anelderly intubated woman who was sedated. Head eyes earsnose and throat examination showed her to be normocephalicatraumatic with bilateral surgical pupils. Neck examinationwas supple with no jugulovenous distension appreciated.There was no
lymphadenopathy
DISEASE
noted. Cardiac examinationshowed a right ventricular heave. It was irregularlyirregular with S1 and S2 and S3 murmur. Her chestexamination was clear to auscultation bilaterally. Herabdomen was soft and distended but nontender. There werebowel sounds in all four quadrants. She was guaiac positivefrom below. Her extremities showed trace
peripheral edema
DISEASE
.There were 2Admission Date: [**2107-12-17**] Discharge Date: [**2107-12-24**]Service: MICUCHIEF COMPLAINT: Hypotension times one day.HISTORY OF PRESENT ILLNESS: The patient is an 89 year oldAfrican-American female admitted in [**7-1**] after v-fib arrest.The patient was defibrillated in the field which wascomplicated by
anoxic encephalopathy
DISEASE
and the patient hasremained vent dependent with PEG at JMR since. The patienthad a large occiput decub debrided on day prior to admissionand was subsequently noted to have persistent
hypotension
DISEASE
with IVF at 75 cc per hour and
atrial fibrillation
DISEASE
at a rategreater than 100. Today labs returned showing white bloodcell count of 50 hematocrit 17 platelets 42 with a systolicblood pressure in the 80s. Temperature was 98.4 heart rate76 respiratory rate 19. The patient was started on dopamineand was not given vanc/ceftaz 1 gm which had been orderedbut not given. The patient was transferred to [**Hospital1 18**] forfurther management. In the emergency room blood pressure was99/49 heart rate 142 temperature 100.6 rectally. Thepatient's blood pressure then dropped to 40/palp and heartrate was 130. EKG at that time showed a-fib with rapidventricular rate. The patient was cardioverted into a slowerrate but still with a-fib. The patient's blood pressurereturned to 120/60. The patient was started onNeo-Synephrine in the emergency room as well. There wereseveral central line attempts made in the left subclavianright groin then left groin with success. The patient wasgiven 2 liters of normal saline and then transferred to theMICU.PAST MEDICAL HISTORY: Significant for
v-fib arrest
DISEASE
complicated by
anoxic encephalopathy
DISEASE
and vent dependent since[**7-1**]. Seizures status post
status epilepticus
DISEASE
in the past.
Anemia
DISEASE
. A-fib with
CHF
DISEASE
. Status post PEG. Chronic renalinsufficiency. GI bleed/gastric
AVM
DISEASE
. Severe
PHTN
DISEASE
.
Thrombocytopenia
DISEASE
.ALLERGIES: No known
drug allergies
DISEASE
.MEDICATIONS ON TRANSFER: Amiodarone 200 mg p.o. q.dayNeurontin 600 mg t.i.d. Flagyl 500 mg p.o. t.i.d.omeprazole 20 mg p.o. b.i.d. Colace 100 mg p.o. b.i.d.captopril 25 mg p.o. t.i.d. Lopressor 12.5 mg p.o. b.i.d.multivitamin Tylenol Darvocet Klonopin.SOCIAL HISTORY: The patient previously lived with family.Now the patient is vent dependent at JMR. No tobacco in thepast. Social ETOH.PHYSICAL EXAMINATION: The patient was an obeseAfrican-American female trached unresponsive indecerebrate positioning in no apparent
respiratory distress
DISEASE
.Vital signs were temperature 98.4 heart rate 70 bloodpressure 115/40. Vent setting AC tidal volume 600respiratory rate 15 PEEP 5 FiO2 50%. The patient wassating 100%. HEENT: 4 to 5 cm occiput decub to skull about8 mm deep. Pupils nonreactive left about 5 mm rightapproximately 3 mm fixed. Anicteric. Positive
pallor
DISEASE
.Neck trached no
lymphadenopathy
DISEASE
JVP not seen secondary tohabitus. Difficult range of motion but not
meningitic
DISEASE
.Chest symmetrical good air exchange and minimal expiratorywheezes bilaterally. CV irregularly irregular heart ratenormal S1 S2 no murmurs rubs or gallops. Abdomen:decreased bowel sounds moderately distended withreproducible
umbilical hernia
DISEASE
. OB positive. Extremities hadno
clubbing cyanosis
DISEASE
positive 2 to 3Admission Date: [**2118-7-18**] Discharge Date: [**2118-7-27**]Date of Birth: [**2042-6-28**] Sex: MService:
CSU
DISEASE
CHIEF COMPLAINT:
Chest pain
DISEASE
and
back pain
DISEASE
.HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 76-year-old manwith a history of
hypertension hyperlipidemia
DISEASE
and prior
myocardial infarction
DISEASE
with a percutaneous transluminalcoronary angioplasty of the right coronary artery in [**2107**] atthe [**Hospital1 69**]. He states that hehas experienced
pain
DISEASE
and
tightness
DISEASE
in his back radiating intoboth shoulders starting on [**2118-7-15**]. The patient denies
shortness of breath dizziness diaphoresis
DISEASE
or
nausea
DISEASE
. The
pain
DISEASE
lasted for 30 seconds following pushing a wheelbarrowand resolved with rest. The patient denied any priorepisodes of
pain
DISEASE
or any since [**2107**] following the initialepisode of
pain
DISEASE
.The patient informs his primary care provider who referredhim to the emergency room. He then presented to [**Hospital3 5363**] where he was ruled out for an
myocardial infarction
DISEASE
by enzymes and electrocardiograms. The patient alsounderwent a negative evaluation for dissecting aortic
aneurysm
DISEASE
. On [**2118-7-16**] the patient began experiencingcontinuing
chest pain
DISEASE
of increasing intensity. He wastreated with nitroglycerin paste and IV Integrelin as well asPlavix. At that time he ruled in for an NST EMI with a peakCK of 412 and a troponin of 6.23. Electrocardiogramsprogressed to inverted T waves in V5 and V6. The patient isnow transferred to [**Hospital1 69**] forcardiac catheterization.PAST MEDICAL HISTORY:
Hypertension hyperlipidemia
DISEASE
IMI in[**2107**].PAST SURGICAL HISTORY: Partial thyroidectomy herniorrhaphypercutaneous transluminal coronary angioplasty of the RCA in[**2107**] left knee surgery as well as
tonsil and adenoid
DISEASE
surgery.ALLERGIES: No known
drug allergies
DISEASE
.MEDICATIONS AT HOME:1. Flomax 0.4 q.d.2. Aspirin 325 q.d.3. Lipitor 10 q.d.4. Naproxen p.r.n. as well as several vitamins and supplements.5. Zestoretic with an unknown dose.MEDICATIONS ON TRANSFER:1. Captopril 25 t.i.d.2. Protonix q.d. 40.3. Nitroglycerin paste 1 inch q. 6 hours.4. Lopressor 25 b.i.d.5. Plavix 75 q.d.6. Lovenox 90 b.i.d.7. Aspirin 325 q.d.8. Lipitor 10 q.d.SOCIAL HISTORY: Married retired accountant with sixchildren. He denies any tobacco use 2 to 3 alcohol drinksper week.FAMILY HISTORY: Father died in his 80's of pacemaker
failure
DISEASE
also had a
myocardial infarction
DISEASE
in his 70's.PHYSICAL EXAMINATION: Vital signs: Heart rate is 55 bloodpressure is 129/79 Respiratory rate is 22 O2 sat is 96percent on 2 liters.In general well-appearing man lying on a stretcher in noacute distress. Neck: 2 plus carotids with no jugular
venous distention
DISEASE
and no
bruits
DISEASE
and no thyromegaly. Lungs:Fine crackles in the bases otherwise clear. Cardiovascular:Regular rate and rhythm S1 and S2 with no murmurs rubs orgallops. Abdomen: Soft and nontender and nondistendednormal
active bowel sounds
DISEASE
and no
bruits
DISEASE
. Pulses are 2 plusfemoral bilaterally 2 plus dorsalis
pedis
DISEASE
as well asposterior tibial bilaterally. No
edema
DISEASE
. Neurological:Alert and oriented times 3.Chest CT done at the outside hospital showed no
gallstones
DISEASE
.Left kidney with a small
cyst splenic lesion
DISEASE
and no triple A.Electrocardiogram has sinus rhythm with Q wave in 2 3 andF flattened T waves in the lateral leads sinus rhythm at arate of 56.LABORATORY DATA: White blood cell count is 8.3 hematocrit42.7 platelets 180 INR was 1.1 sodium 135 potassium 4.0chloride 99 CO2 33 BUN 13 creatinine 1.0 glucose 96.While on transfer the patient underwent cardiaccatheterization. Please see cathed report for full details.In summary the catheterization showed left main with no
obstructive disease
DISEASE
LAD with 70 percent serial lesion leftcircumflex with 70 percent proximal OM1 and OM2 both 70percent lesions RCA with
nonobstructive disease
DISEASE
and ejectionfraction of 25 percent.The patient was referred to CT surgery who was seen andaccepted for coronary artery bypass grafting. On [**7-19**] hewas brought to the Operating Room please see the OperatingRoom report for full details. In summary he had a coronaryartery bypass graft times 4 with a LIMA to the LAD saphenousvein graft OM1 saphenous vein graft OM2 and saphenous veingraft of the diagonal. His bypass time was 105 minutes witha cross clamp time of 87 minutes. He tolerated the operationwell and was transferred from the Operating Room to thecardiothoracic ICU.At the time of transfer he was AV paced at a rate of 88beats per minute. He had Propofol at 30 mc per kg per minuteand Neo-Synephrine to maintain his blood pressure. Thepatient did well in the immediate postoperative period. Hisanesthesia was reversed. He was weaned from the ventilatorand successfully extubated. He remained hemodynamicallystable throughout the remainder of his operative day. Onpostoperative day 1 the patient remained hemodynamicallystable on a Neo-Synephrine drip to maintain an adequate bloodpressure. He remained in the Intensive Care Unit as he wasunable to be weaned off of his Neo-Synephrine drip.On postoperative day 1 his Swan-Ganz catheter was removed aswell. On postoperative day 2 another attempt was made towean the patient off of Neo-Synephrine unsuccessfully. Hischest tubes were removed. However because he could not beweaned from the Neo-Synephrine he again remained in theIntensive Care Unit. On postoperative day 3 an additionalattempt was made to wean the patient from his Neo-Synephrineunsuccessfully. The patient also received a unit of packedred blood cells in an additional attempt to wean from Neo-Synephrine. This also did not help in the attempt to weanfrom Neo-Synephrine. His Foley catheter was removed and heremained again in the ICU.On postoperative day 4 additional attempts were made to weanthe patient off of his Neo-Synephrine however he continuedto drop his blood pressure whenever an attempt was made.Other than that the patient remained completely stable. Onpostoperative day 5 the patient was finally weaned off ofhis Neo-Synephrine and diuresis was begun. He remained inthe Intensive Care Unit for an additional day to monitor hishemodynamics. On postoperative day 6 the patient remainedhemodynamically stable and he was transferred to the floorfor continuing postoperative care and cardiac rehabilitation.Over the next two days the patient had an uneventfulhospitalization. His activity level was increased with theassistance of physical therapy department and the nursingstaff. On postoperative day 7 it was decided that thepatient would be stable and ready to be discharged to home onthe following day.At the time of this dictation the patient's physicalexamination is as follows: Vital signs were temperature 99heart rate 84 in sinus rhythm blood pressure was 114/63Respiratory rate was 18 O2 sat was 94 percent on room air.Weight preoperatively was 88.5 kilos at discharge was 90.4kilos.LABORATORY DATA: White blood cell count 8.8 hematocrit29.7 platelets 367 sodium 139 potassium 4.7 chloride 102CO2 27 BUN 17 creatinine 1.1 glucose 95.PHYSICAL EXAMINATION: Neurological: Alert and oriented times3. Moves all extremities and follows commands. Respiratory:Clear to auscultation bilaterally. Cardiovascular: Regularrate and rhythm S1 and S2. No murmurs. Sternum is stableincision with staples opened to air clean and
dry
DISEASE
.Abdomen: Soft and nontender nondistended with positive bowelsounds. Extremities: Warm and well profuse with 1 to 2 plus
edema
DISEASE
. Right saphenous vein graft site with Steri-stripsopen to air clean and
dry
DISEASE
.The patient's condition at discharge is good.DISCHARGE DIAGNOSIS:1.
Coronary artery disease
DISEASE
status post coronary artery bypass grafting times 4 with LIMA to the LAD saphenous vein graft to OM1 saphenous vein graft to OM2 and saphenous vein graft to the diagonal.2.
Hypertension
DISEASE
.3.
Hypercholesterolemia
DISEASE
.4. Status post partial thyroidectomy.5. Status post
hernia
DISEASE
repair.6. Status post left knee surgery.7. Status post tonsil and adenoid surgery.DISCHARGE MEDICATIONS:1. Atorvastatin 10 mg q.d.2. Plavix 75 mg q.d. times 3 months.3. Aspirin 325 mg q.d.4. Lasix 20 mg q.d. times two weeks.5. Potassium chloride 20 mEq q.d. times two weeks.6. Metoprolol 12.5 mg b.i.d.7. Percocet 1 to 2 tabs q. 4 hours p.r.n.The patient is to be discharged home with visiting nurses.He is to have follow up in the wound clinic in two weeks andfollow up with Dr. [**Last Name (STitle) 3321**] in two to three weeks andfollow up with Dr. [**Last Name (STitle) **] in 4 weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**] [**MD Number(1) 1715**]Dictated By:[**Last Name (NamePattern4) 1718**]MEDQUIST36D: [**2118-7-27**] 12:52:27T: [**2118-7-27**] 13:28:05Job#: [**Job Number 5364**]Admission Date: [**2191-6-21**] Discharge Date: [**2191-6-24**]Date of Birth: [**2133-2-24**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2901**]Chief Complaint:transfer from cath lab s/p
cardiac arrest
DISEASE
at OSHMajor Surgical or Invasive Procedure:1. Cardiac Catheterization s/p LAD stentHistory of Present Illness:58 yo M with h/o
HTN hyperlipidemia
DISEASE
no known CAD transferredfrom OSH s/p V-fib arrest [**12-30**] AMI. Patient reports having chest
pain
DISEASE
back
pain
DISEASE
under
left scapula
DISEASE
and
left shoulder pain
DISEASE
starting at 6 pm on [**6-20**] while he was driving. He took 2 ASA atthat time the
pain
DISEASE
stopped then started again later on. Patientthen went home and developed severe
pain
DISEASE
while at rest which didnot resolve. He was driving to [**Hospital3 5365**] ED by his wife.At the OSH patient found to have ST elevations in V2-V6 wentinto V-fib s/p two
shock
DISEASE
at 200J then 360 J (down 7 min perflow sheet) patient started on lidocaine nitro gtt'sintegrilin and heparin started. He was AAdmission Date: [**2155-2-18**] Discharge Date: [**2155-3-6**]Date of Birth: [**2075-3-16**] Sex: MService: MEDICINE
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 5368**]Chief Complaint:R arm shaking and
confusion
DISEASE
Major Surgical or Invasive Procedure:Cystoscopy CKU procedure by UrologyHistory of Present Illness:79 year old man with history of
diabetes
DISEASE
and
hypertension
DISEASE
whopresents with new onset
seizures
DISEASE
. His wife found it unusualthat he picked her up from work late that day around 2 pm. Whenthey got home at arond 3:30pm he was staring straight at the TVfor 10 minutes and not responding to his wife. [**Name (NI) **] thenproceeded to go take his pills but his wife [**Name (NI) 5369**] him becausehe had already taken them this morning. After the starringepisode his wife asked if he was okay but he kept repeating Admission Date: [**2162-3-3**] Discharge Date: [**2162-3-25**]Date of Birth: [**2080-1-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1828**]Chief Complaint:Mr. [**Known lastname 1829**] was seen at [**Hospital1 18**] after a mechanical fall froma height of 10 feet. CT scan noted unstable
fracture
DISEASE
of C6-7 &posterior elements.Major Surgical or Invasive Procedure:1. Anterior cervical osteotomy C6-C7 with decompression andexcision of
ossification
DISEASE
of the posterior longitudinal ligament.2.
Anterior cervical deformity
DISEASE
correction.3. Interbody reconstruction.4. Anterior cervical fusion C5-C6-C7.5. Plate instrumentation C5-C6-C7.6. Cervical laminectomy C6-C7 T1.7. Posterior cervical arthrodesis C4-T1.8. Cervical instrumentation C4-T1.9. Arthrodesis augmentation with autograft allograft anddemineralized bone matrix.History of Present Illness:Mr. [**Known lastname 1829**] is a 82 year old male who had a
slip
DISEASE
and fallof approximately 10 feet from a balcony. He was ambulatory atthe scene. He presented to the ED here at [**Hospital1 18**]. CT scanrevealed unstable C spine
fracture
DISEASE
. He was intubated secondaryto
agitation
DISEASE
.Patient admitted to
trauma
DISEASE
surgery servicePast Medical History:
Coronary artery disease
DISEASE
s/p CABG
CHF
DISEASE
HTN
DISEASE
AICD
Atrial fibrillation
DISEASE
Stroke
DISEASE
Social History:Patient recently discharged from [**Hospital1 **] for severe
depression
DISEASE
. Family reports patient was very sad and attempted tokill himself by wrapping a telephone cord around his neck. Liveswith his elderly wife worked as a chemist in [**Country 532**].Family History:Non contributoryPhysical Exam:Phycial exam prior to surgery was not obtained since patient wasintubated and sedated.Post surgical physical exam: (TSICU per surgery team)Breathing without assistanceNADVitals: T 97.5 HR 61 BP 145/67 RR22 SaO2 98A-fib rate controlledAbd soft non-tenderAnterior/Posterior cervical incisions [**Name (NI) 1830**]Pt is edemitous in all four extremities no facial
edema
DISEASE
Able to grossly move all four extremities neurointact to lighttouchDistal pulses weakly intactMedicine Consult:VS: Tm/c 98.9 142/70 61 20 96%RAI/O BM yesterday 220/770Gen: awake calm cooperative and pleasant lying in bedNeck: c-collar removedCV: irregular normal S1 S2. No m/r/g.lungs: cta anteriolryAbd: Obese Soft NTND decreased bsExt: trace b/l le
edema
DISEASE
1Admission Date: [**2194-8-15**] Discharge Date: [**2194-8-16**]Service: MEDICINE
Allergies
DISEASE
:Lisinopril / Nsaids / NesiritideAttending:[**First Name3 (LF) 1881**]Chief Complaint:
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:
HD
DISEASE
History of Present Illness:Ms. [**Known lastname **] is a 86F with h/o
colon cancer ESRD
DISEASE
onhemodialysis diastolic CHF pulmonary hypertension and prior
cephalic vein thrombosis
DISEASE
who presented to the ED on [**8-15**] with
dyspnea
DISEASE
.The patient's dialysis catheter became dislodged [**8-12**].Consequently she missed her normal dialysis session [**8-13**]. On[**8-14**] she had a new tunneled catheter placed but was notdialyzed. The afternoon of [**8-14**] her daughter noticed that thepatient seemed increasingly dyspneic and was
hypertensive
DISEASE
to200's. She was given hydralazine and clonidine and the BPimproved to 160's. She called her daughter Admission Date: [**2155-9-15**] Discharge Date: [**2155-9-22**]Date of Birth: [**2075-3-16**] Sex: MService: NEUROLOGY
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 5378**]Chief Complaint:Altered consciousness right arm shaking.Major Surgical or Invasive Procedure:None.History of Present Illness:The pt. is an 80 year-old right-handed gentleman who presentedon [**2155-9-15**] with several hours of decreased responsiveness. Perthe pt's wife the patient awoke around 6:00 on the morning ofadmission and was mumbling seemed to have
trembling
DISEASE
of lips. Hesat at the side of the bed and at 6:30 wife asked him to takehis medications and he has not responsive to her. He keptrepeating Admission Date: [**2119-11-23**] Discharge Date: [**2119-11-27**]Service:HISTORY OF PRESENT ILLNESS: This is an 83 year old womanwith
myeloproliferative disorder
DISEASE
who is on a baby aspirin aday who presented with
melena
DISEASE
and coffee ground
emesis
DISEASE
. Twodays prior to admission the patient was fatigued butotherwise well. One day prior to admission the patientstarted feeling diffuse
abdominal pain
DISEASE
all day felt
nausea
DISEASE
vomiting
DISEASE
of coffee grounds in the evening and then
melena
DISEASE
.The patient admits to being lightheaded at that time withincreasing lightheadedness this morning.She denies any
chest pain palpitations shortness of breath
cough orthopnea
DISEASE
sick contacts or suspicious foods. Shewent to the Emergency Room where her vital signs revealed atemperature of 97.9 F.Admission Date: [**2123-6-12**] Discharge Date: [**2123-6-18**]Service: MEDICINE
Allergies
DISEASE
:EnalaprilAttending:[**First Name3 (LF) 1845**]Chief Complaint:Bright red blood per rectum x 2Major Surgical or Invasive Procedure:Colonoscopy on [**2123-6-14**]History of Present Illness:86 yo woman with h/o
diverticulosis
DISEASE
and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear/PUDon PPI [**Last Name (NamePattern4) 5390**]/MDS presents with BRBPR. Pt was in her usualhealth until 3am today when she woke up to have a BM. Whilehaving BM noted Admission Date: [**2125-11-14**] Discharge Date: [**2125-11-20**]Service: MEDICINE
Allergies
DISEASE
:Enalapril / AmlodipineAttending:[**First Name3 (LF) 4760**]Chief Complaint:
Shortness of breath
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:This is a 89 year-old female with a history of
MDS
DISEASE
hipfracuture [**2-16**] living at [**Doctor Last Name 5396**]Rehab who presents with
shortness of breath
DISEASE
. Per nursing home staff patient has beencoughing with
chest congestion fatigue
DISEASE
and poor PO intake for1 week. Additionally staff states that she is the 4th patienthospitalized for pnemonia and th 10th with
chest cold symptoms
DISEASE
and
fevers
DISEASE
..CXR on [**11-6**] was without cardiopulmonary process and labs weresignificant for Hct of 60 WBC 26.3 (90%neut 1%lymph) Cr of1.5 and proBNP of 6000 (3000 1 month earlier). Patient wasstarted on Lasix 40mg [**Hospital1 **] for presumed
CHF
DISEASE
exacerbation butcontinued to have
cough fatigue
DISEASE
poor PO intake and on [**11-14**]desated to the 70's..In the ED patient's initial vitals were T 96.6 BP 111/58 HR64 RR 30 sating 90% on NRB. While in ED she spiked to 101.8with continued low sat on
NRB
DISEASE
and was placed on BiPAP as patientis DNR/DNI. BP dropped to 83/41 but responded to 1L NS back to102/41. [**Month/Day (1) **] Cx sent and patient was given Vanc and Cefipime..On ROS patient was oriented x 2 (did not know which hospital).ROS likley inaccurate as patient denied Fevers/chills and SOBwhich were documented in ED..Past Medical History:
Myeloproliferative syndrome
DISEASE
Hypothyroidism
DISEASE
GI bleeds
DISEASE
diverticular last [**6-15**]R bell's palsy
Hypertension
DISEASE
Osteoporosis
DISEASE
s/p hip
fracture
DISEASE
with surgical treatment [**2-/2125**] ([**Hospital3 **])One previous episode of
atrial fibrillation
DISEASE
.Social History:Has lived in rehab at [**Doctor Last Name 5396**]in [**Hospital1 **] since hip surgery[**2-/2125**] ambulates with cane or walker.No smoking quit 35 years ago about 20-30 pack year history noalcohol no drug use.Family History:The patient's mother died of
peritonitis
DISEASE
.The patient's father had an unknown
cancer
DISEASE
. No history of
gastrointestinal bleeding
DISEASE
in the familyPhysical Exam:Vitals: T: 98.5 BP: 102/42 HR: 97 RR: 17 O2Sat: 95% BiPAP 10/540%GEN: No acute distress elderly woman mildly somnolent withBiPAP mask onHEENT: EOMI PERRL sclera anicteric no
epistaxis
DISEASE
orrhinorrhea MM dryNECK: No JVD carotid pulses brisk no bruits no cervical
lymphadenopathy
DISEASE
trachea midlineCOR: Tachy but regular no M/G/R normal S1 S2 radial pulses Admission Date: [**2136-10-23**] Discharge Date: [**2136-11-21**]Date of Birth: [**2080-8-23**] Sex: FService:HISTORY OF PRESENT ILLNESS:Patient is a 56-year-old woman previously healthy and begandeveloping a diffuse mild
headache
DISEASE
and discomfort in [**Month (only) **].Complained of left arm weakness toward the end of [**Month (only) 216**]lasting a few minutes and since then has had four similarepisodes. Approximately a month ago she had slight change inthe character of the
headache
DISEASE
. It is now constant diffuse
pain
DISEASE
with some
nausea
DISEASE
[**7-20**] severity at its worse. In somedays is
pain
DISEASE
free. No history of nonsteroidalanti-inflammatory or aspirin use. Sometimes the occipitalportion of the
headache
DISEASE
improves with sleep approximately thesame time she noted unsteady gait and falls to the left. Shehad an occipital steroid injection with transientimprovement.PAST MEDICAL HISTORY:Benign.PAST SURGICAL HISTORY:Bowel surgery in [**2128**] for
obstructive volvulus
DISEASE
.REVIEW OF SYSTEMS:General appearance: Denies fever or
chills
DISEASE
. Positive weightloss over the last three months [**4-19**] lb with no
chest pain
DISEASE
shortness of breath palpitations abdominal pain
DISEASE
no changein
bowel or urinary habits
DISEASE
.PHYSICAL EXAMINATION:Skin is warm and
dry
DISEASE
. Head is normocephalic atraumatic.Eyes: Sclerae are anicteric. Throat: Pharynx is pinkclear without
exudate
DISEASE
or drainage. Teeth intact. Gums arepink and moist. Tongue normal. Neck is supple without
jugular venous distention
DISEASE
. Heart regular rate and rhythmwithout murmurs rubs or gallops. Chest was clear toauscultation. Abdomen is soft nondistended positive bowelsounds. Extremities: No
clubbing cyanosis
DISEASE
or
edema
DISEASE
.Neurologically visual fields are full to confrontation. Herpupils are equal round and reactive to light. Her cranialnerves are intact. Her motor strength is [**4-14**] in all musclegroups. Her reflexes are 2Admission Date: [**2140-1-16**] Discharge Date: [**2140-1-23**]Service:CHIEF COMPLAINT: Shortness of breath.HISTORY OF PRESENT ILLNESS: This is an 86 year old femalewho has had recent multiple admissions to the hospital for
shortness of breath
DISEASE
who was admitted on [**2140-1-16**] fromrehabilitation with
listlessness
DISEASE
and a blood pressure in thelow range of 100/60. She also had an oxygen saturation of88% on two liters. The patient's primary care physician [**Last Name (NamePattern4) **].[**Last Name (STitle) 3357**] assessed the patient and she was sent to [**Hospital1 346**] Emergency Department for evaluationfor
congestive heart failure
DISEASE
. She had some wheezes onexamination and was given Albuterol and Ipratropiumnebulizers and Lasix 40 mg intravenously. Her blood pressureon admission to Emergency Department triage was approximately80/60 which was lowered to 74/23. Dopamine drip was startedfor blood pressure support and the patient was admitted toIntensive Care Unit and given two liters of normal saline.She was noted to be 88% in room air and got antibiotics forpossible
pneumonia
DISEASE
. She was placed on an eight liter facemask and had an arterial blood gases of 7.30 with a pCO2 of47 and a pO2 of 58. She was in the Intensive Care Unit forthree hospital days and was transferred out to the Medicinefloor after it was determined that she was likely dehydratedand went into
renal failure
DISEASE
due to
dehydration
DISEASE
and possibleover diuresis.PAST MEDICAL HISTORY:1. Multi-infarct
dementia
DISEASE
.2. Coronary artery disease status post pacer for complete
heart block
DISEASE
.3.
Diabetes mellitus
DISEASE
.4. Depression.5. Congestive
heart failure
DISEASE
.6. Status post radial
fracture
DISEASE
.7. Bilateral knee arthroplasty.MEDICATIONS ON ADMISSION:1. Colace.2. Vitamin D.3. Lipitor 10 mg p.o. once daily.4. Aspirin 81 mg p.o. once daily.5. Lopressor 50 mg p.o. twice a day.6. Imdur 90 mg p.o. once daily.7. Lisinopril 20 mg p.o. once daily.8. Ultram 50 mg p.o four times a day.9. Protonix 40 mg p.o. once daily.10. Lasix 20 mg p.o. once daily.11. Zyprexa 10 mg p.o. twice a day.12. Effexor 75 mg p.o. once daily.13. Effexor XR 150 mg p.o. q.h.s.14. Neurontin 300 mg p.o. twice a day.PHYSICAL EXAMINATION: Upon presentation to Medicinetemperature is 96.9 blood pressure 103/63 heart rate 86respiratory rate 27 oxygen saturation 96% in room air. Ingeneral she is sitting in bed bright and alert. Headeyes ears nose and throat examination reveals moist mucousmembranes with a clear oropharynx. The lungs show slightcrackles at the left base and no audible wheezes.Cardiovascular reveals a regular rate and rhythm with distantheart sounds. Abdomen is soft obese nontendernondistended with positive bowel sounds. Extremities show nopedal
edema
DISEASE
.LABORATORY DATA: Upon presentation to Medicine white bloodcell count was 9.1 hematocrit 35.6 platelet count 326000.Creatinine 1.1 blood urea nitrogen 27 potassium 5.2glucose 171.HOSPITAL COURSE:1. Dyspnea
hypoxia
DISEASE
- She was much improved after gettingfluids in the Intensive Care Unit without any diuresis. Itwas determined by chest x-ray that she was
dry
DISEASE
and hadpossible infiltrate and was treated with antibioticsLevofloxacin Flagyl Vancomycin. The Vancomycin wasdiscontinued however she remained on Levofloxacin andFlagyl for concern of aspiration
pneumonia
DISEASE
. Intensive CareUnit team also felt that the patient had reactive airways andstarted steroids p.o. along with continuing nebulizers. Shehad a negative infectious workup to date. Of note she hasnot had a history of
chronic obstructive pulmonary disease
DISEASE
or
asthma
DISEASE
in the past. Upon transfer to the Medicine floor shewas found the next day to be in significant respiratorydistress requiring respirator care and nebulizers. Sheseemed to do better after this. Chest x-ray was obtained andshowed progressive
heart failure
DISEASE
over the past four days inthe hospital. She was given 20 mg intravenous Lasix and hadgood urine output and was saturating well. She then becamevery lethargic and was given intravenous fluids as it isnoted in the past the patient responds very well tointravenous fluids becoming more alert and aware of herenvironment. Also of note the patient had a transthoracicechocardiogram which showed an ejection fraction of 55% andE:A ratio of 0.82 however this did not meet criteria for
diastolic dysfunction
DISEASE
. She also had a very poor qualityechocardiogram which limited our evaluation of whether shehas
systolic dysfunction
DISEASE
in addition to diastolicdysfunction. A
heart failure
DISEASE
consultation was obtained by Dr.[**Last Name (STitle) **] and it was determined that it was difficult to tellwhether she had pure
diastolic dysfunction
DISEASE
. It wasrecommended that the patient start Diltiazem for rate controlwithout using beta blockers to exacerbate any potential
bronchospasm
DISEASE
. The patient did well on Diltiazem and wascontinued only on Lisinopril 5 mg p.o. once daily. Herprevious Imdur and Lopressor were discontinued.2.
Hypotension
DISEASE
- It was unclear whether the patient wasovermedicated with blood pressure medications upon admissionor was over-diuresed. Her previous hospital stay hadactually cut down her previous Lasix dose so it is unclearwhether this had anything to do with her
hypotension
DISEASE
.However while in house the patient's blood pressureremained well without Lopressor or Lisinopril at 20 mg. Atthe reduced Lisinopril dose as well as the Diltiazem thepatient did well. She was restarted on her Lasix 20 mg p.o.Once daily.CONDITION ON DISCHARGE: Good.DISCHARGE STATUS: To [**Hospital 5412**] Rehabilitation.DISCHARGE DIAGNOSES:1. Multi-infarct
dementia
DISEASE
.2. Coronary artery disease status post pacer for complete
heart block
DISEASE
.3.
Diabetes mellitus
DISEASE
.4. Depression.5. Congestive
heart failure
DISEASE
.6. Status post radial
fracture
DISEASE
.7. Bilateral knee arthroplasty.MEDICATIONS ON DISCHARGE:1. Diltiazem XR 120 mg p.o. once daily hold for systolicblood pressure of less than 110.2. Prednisone 40 mg p.o. twice a day on a taper to decreaseby 10 mg twice a day every two days.3. Metronidazole 500 mg p.o. three times a day.4. [**2140-1-23**] is her last day of Levofloxacin 250 mg p.o.once daily.5. [**2140-1-23**] is her last day of Acetamodic.6. Gabapentin 300 mg p.o. twice a day.7. Phenylfaxene SR 75 mg p.o. once daily.8. Lisinopril 5 mg p.o. once daily.9. Ipratropium MDI two puffs inhaled four times a day.10. Albuterol MDI one to two puffs inhaled q4hours p.r.n.11. Olanzapine 10 mg p.o. twice a day.12. Vitamin D 400 units p.o. once daily.13. Docusate 100 mg p.o. twice a day.14. Aspirin 81 mg p.o. once daily.15. Atorvastatin 10 mg p.o. once daily.FOLLOW-UP PLANS: The patient is to follow-up with herphysician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3357**]. [**Name6 (MD) 251**] [**Name8 (MD) **] M.D. [**MD Number(1) 1197**]Dictated By:[**Name8 (MD) 4064**]MEDQUIST36D: [**2140-1-23**] 08:39T: [**2140-1-23**] 09:13JOB#: [**Job Number 5413**]Admission Date: [**2140-4-23**] Discharge Date: [**2140-4-27**]Service: ACOVEHISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 5419**] is an 87 year-oldRussian female with a past medical history significant for
multi infarct dementia coronary artery disease
DISEASE
diastolicdysfunction
type 2 diabetes
DISEASE
pacemaker for
heart block
DISEASE
deep
venous thrombosis
DISEASE
and PE and aspiration of thin liquids whopresented from her nursing home on [**2140-4-23**] after thecaretakers at the nursing home noticed an area of
erythema
DISEASE
and
tenderness
DISEASE
on the patient's left lower concern. Theirconcern was for a
cellulitis
DISEASE
. The patient was also noted tobe sleepy more so then her baseline with a decreased room airsaturation. In the Emergency Department the patient wasafebrile. She was in no acute distress. There was an areaon her left lateral upper calf that was erythematous andslightly warm likely a
cellulitis
DISEASE
. The patient was treatedwith Ancef 1 gram intravenous. She was also given Flagyl 500mg intravenous and Levaquin 500 mg intravenous for questionof an aspiration
pneumonia
DISEASE
with the patient's history ofaspiration and the drop in room air sats to 89%. Thissaturation improved to 97% on 2 liters. The patient had achest x-ray that was read s fluid in the fissure but cannotrule out a retrocardiac infiltrate. Therefore the patientwas admitted for management of
cellulitis
DISEASE
and possible
pneumonia
DISEASE
.PAST MEDICAL HISTORY:1. Multi
infarct dementia
DISEASE
. At baseline the patient is notalert and oriented times three but is responsive.2.
Coronary artery disease
DISEASE
.3. Congestive
heart failure
DISEASE
diastolic last EF fromechocardiogram on [**2140-2-23**] was super normal read as 75 to 80%with an E to A ratio of 0.55 normal left ventricular wallthickness.4.
Diabetes mellitus
DISEASE
type 2.5. Pacemaker for complete
heart block
DISEASE
.6. Depression.7. Status post
cataract
DISEASE
surgery.8.
Hypertension
DISEASE
.9. Diagnosed with deep
venous thrombosis
DISEASE
and PE in [**2140-2-13**] now on Coumadin.10. History of E-coli
urinary tract infection
DISEASE
resistant toLevofloxacin.11.
Pneumonia
DISEASE
in [**2140-1-13**] possibly related toaspiration.12. Aspiration of thin liquids. The patient had a speechand swallow study on [**2140-1-21**] that was interpreted asaspiration of thin liquids with the recommendation that thepatient have nectar thick liquids and purees and bepositioned upright for all po intake.ALLERGIES: No known
drug allergies
DISEASE
.MEDICATIONS ON ADMISSION:1. Colace 100 b.i.d.2. Vitamin D 400 units q.d.3. Lipitor 10 q.d.4. Aspirin 81 q.d.5. Effexor 75 q.d.6. Neurontin 300 b.i.d.7. Protonix 40 q.d.8. Lasix 20 mg q 72 hours.9. Zyprexa 10 b.i.d.10. Coumadin 2 mg q.d.11. Albuterol MDI.12. Atrovent MDI.13. Regular insulin sliding scale.SOCIAL HISTORY: The patient speaks only Russian. She livesin a nursing home and has resided there for at least fiveyears. Her son is very involved in her care.PHYSICAL EXAMINATION ON ADMISSION: Temperature 96.9. Pulse62 and regular. Blood pressure 118/54. Respiratory rate 20.Sat 97% on 2 liters. In general the patient was felt to beill appearing and in no acute distress very sleepy uneasyto arouse. HEENT mucous membranes are
dry
DISEASE
. Pupils areequal round and reactive to light and accommodation. Necksupple. Lungs clear to auscultation bilaterally with diffuse
expiratory wheezing
DISEASE
.
Cardiovascular distant heart sounds
DISEASE
S1and S2 2 out of 6
systolic ejection murmur
DISEASE
at the rightupper sternal border. Abdomen soft obese nontenderpositive bowel sounds. Extremities area on the left uppercalf of
erythema
DISEASE
roughly 2 cm by 2 cm nonpainful nontenderno skin breakdown or open areas. Neurological sleepy openseyes to commands otherwise cannot comply well withneurological examination. Per records this is the patient'sbaseline.LABORATORY DATA ON ADMISSION: White blood cell count 10.5hematocrit 33.2 platelets 351 creatinine 1.0 glucose 157INR 1.6.IMAGING: The patient had a left lower extremity ultrasoundwhich showed no evidence of deep
venous thrombosis
DISEASE
. Chestx-ray showed slight obscurating of the left hemidiaphragmquestion infiltrate.IMPRESSION: This is an 87 year-old Russian only speakingfemale with multiple medical problems including
dementia
DISEASE
coronary artery disease congestive heart failure
DISEASE
deep
venous thrombosis
DISEASE
and PE presenting with a left leg
cellulitis
DISEASE
.For the patient's
cellulitis
DISEASE
she was initially continued onUnasyn with her history of
diabetes
DISEASE
and a concern for acomplicated
infection
DISEASE
. For the question of
pneumonia
DISEASE
thepatient was not placed on antibiotics as it was felt that shedid not have a
pneumonia
DISEASE
based on the absence of an elevatedwhite count the absence of
cough
DISEASE
or
fever
DISEASE
and the absence ofsputum production. For the patient's recent history of PEand deep
venous thrombosis
DISEASE
with an INR of only 1.6 thepatient was continued on Coumadin and also given Lovenoxuntil her INR was therapeutic.HOSPITAL COURSE: 1. Infectious disease: For the patient'spresumed
cellulitis
DISEASE
she was treated with Dicloxacillin 250 mgpo q.i.d. The Unasyn was discontinued as even though thepatient is a
diabetic
DISEASE
she had no open areas and the
cellulitis
DISEASE
appeared very mild and there was no skinbreakdown. There was improvement in her
cellulitis
DISEASE
duringher hospital stay with a po Dicloxacillin. The patient wasruled out for other etiologies of
infection
DISEASE
. The chest x-rayappeared without infiltrate. Her urine showed no evidence of
infection
DISEASE
. The patient remained afebrile.2. Hematology: The patient's INR by the morning of hospitalday number two was 2.3 therefore the Lovenox wasdiscontinued and the patient was continued on Coumadin.3. Hypotension: The patient is on a dosing regimen of Lasix20 po q 72 hours for her history of
diastolic dysfunction
DISEASE
.She was continued on this while in house initially. On theevening of [**2140-4-23**] the house staff was called to see thepatient for
tachypnea
DISEASE
decreased O2 sats to 88% on room air.The patient was normotensive at this time. On physicalexamination she was tachypneic with a respiratory rate in the30s. She was diaphoretic in appearance with diffuseexpiratory
wheezing
DISEASE
on lung examination without crackles. Onexamination of her extremities she had 1Admission Date: [**2153-9-25**] Discharge Date: [**2153-9-28**]Date of Birth: [**2090-1-5**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 106**]Chief Complaint:s/p EtOH ablation of interventricular septum for
Hypertrophic
obstructive cardiomyopathy
DISEASE
Major Surgical or Invasive Procedure:Ethanol ablation of Myocardial interventricular septumHistory of Present Illness:Patient is a 63 yo male with PMH significant for hypertrophic
cardiomyopathy COPD hypertension
DISEASE
and recently diagnosed
Afib
DISEASE
admitted after undergoing EtOH ablation of the interventricularseptum. The patient has had DOE with chest pressure since 1year. Says that he used to get SOB and CP while walking up onlya slight incline. He denies symptoms at rest. He does haveperiodic leg
edema
DISEASE
which he treats with diuretics. He sleeps ontwo pillows for comfort.
Denies claudication
DISEASE
PNDlightheadedness. Gives h/o occasional
palpitations
DISEASE
of about fewseconds since 1 year. In early [**2153-8-19**] pt had CP and
diaphoresis
DISEASE
at rest which subsided after some time. Next day hewent to play golf but soon developed SOB and CP and had to beadmitted to [**Hospital3 **]. Troponin was borderline positive/CK'snegative and he was transferred to [**Hospital1 18**] for cardiaccatheterization which revealed a significant subaortic valvepressure gradient that increased with Valsalva. He was found in
atrial fibrillation
DISEASE
during the admission and discharged onCoumadin which he stopped taking on [**9-18**]. He now came infor ethanol ablation of the myocardial interventricular septum.Past Medical History:1)Hypertrophic
cardiomyopathy
DISEASE
(diagnosed 3 years ago)2)Hypertension3)COPD4)Low back
pain
DISEASE
secondary to
herniated disc
DISEASE
5)Atrial fibrillation
DISEASE
(newly diagnosed)6)s/p Cataract surgery7)Remote knee surgeries8)Thalasemia minorSocial History:Patient is single and lives alone. He has two chdilren.Pt smoked 1ppd x 40-50yrs and quit 10 yrs ago.1-2 beers/dayFamily History:Mother w/MIPhysical Exam:vitals BP 142/73 HR 40-50 (irregular) RR 14 O2 Sat Admission Date: [**2166-3-21**] Discharge Date: [**2166-4-4**]Service: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 165**]Chief Complaint:
chest pain
DISEASE
radiating to backMajor Surgical or Invasive Procedure:Emergency repair of acute type A aortic dissection withascending aortic and hemiarch replacement with a size 26Gelweave graft.Aortic valve resuspension.History of Present Illness:[**Age over 90 **]yo F BIBA from home c/o
chest pain
DISEASE
radiating to back. InEDpt acutely decompensated becoming tachycardichypotensiveunresponsive. She was intubated. Hemodynamicsimproved on dopamine. Echo reveals
pericardial effusion
DISEASE
with
tamponade
DISEASE
CXR reportedly reveals widened mediastinum. Cardiacsurgery is called for emergent evaluation. She does have a h/oasc. aortic
aneurysm
DISEASE
of 4.2cmPast Medical History:- Diastolic
CHF
DISEASE
last echo [**10-29**] with (LVEFAdmission Date: [**2131-6-9**] Discharge Date: [**2131-6-16**]Date of Birth: [**2064-5-17**] Sex: FService: [**Hospital1 **]HISTORY OF PRESENT ILLNESS: The patient is a 67 year oldfemale with a long medical history including atrial
fibrillation
DISEASE
without Coumadin (the patient declined)
supraventricular tachycardia
DISEASE
post ablation times twomultiple sclerosis
myasthenia
DISEASE
[**Last Name (un) 2902**]
migraines
DISEASE
andprescription medication abuse who presented to the EmergencyRoom on [**2131-6-8**] complaining of
episodic speech arrest
DISEASE
for two days and
nausea diarrhea
DISEASE
and
headache
DISEASE
for one day.The patient was in her usual state of health until [**2131-6-6**] when she experienced several episodes of
speech arrest
DISEASE
while in the car with her husband. The next day she awokewith severe
headache
DISEASE
and
nausea
DISEASE
with
diarrhea
DISEASE
and
vomiting
DISEASE
times four in addition to her episodic
speech arrest
DISEASE
.Her primary care physician saw her and drew blood whichrevealed a potassium of 2.9. MRI showed periventricularwhite matter changes by the inferior [**Doctor Last Name 534**] of the rightlateral ventricle as well as left
mastoiditis
DISEASE
. Her symptomscontinued the next day with
headache
DISEASE
and
vomiting
DISEASE
times twoas well as
speech arrest
DISEASE
. The patient went to the [**Hospital1 1444**] Emergency Department.In the Emergency Room her vital signs were temperature 97.0F.Admission Date: [**2198-7-17**] Discharge Date: [**2198-8-4**]Date of Birth: [**2132-6-25**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 1406**]Chief Complaint:
Dyspnea
DISEASE
Major Surgical or Invasive Procedure:[**2198-7-25**]1. Left atrial appendage resection.2. Coronary artery bypass grafting x3: Left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the posterior descending artery and obtuse marginal artery.3. Aortic valve replacement with a 25-mm St. [**Male First Name (un) 923**] Epic tissue valve model #EFT100-25- 00.History of Present Illness:66 year old male who presented with worsening shortness ofbreath and
hypotension
DISEASE
. He presented to his PCP's office forfollow up and was noted to be short of breath and
hypotensive
DISEASE
with SBP's in the 80's. His symptomsstarted approximately 2-3 weeks prior to presentation. He mainlyhad difficulty with
shortness of breath
DISEASE
. This shortness ofbreathwould prevent him from sleeping comfortably. He describessymptoms consistent with
orthopnea
DISEASE
and PND. He notes that he sawDr. [**Last Name (STitle) **] a couple of weeks ago and was started on lasix andaldactone. He was also noted to be in
atrial fibrillation
DISEASE
atthattime as well. He is now being referred to cardiac surgery forevaluation of revascularization and possible aortic valvereplacement.Past Medical History:
Atrial fibrillation
DISEASE
Coronary Artery Disease
DISEASE
Aortic Stenosis
DISEASE
PMH:
Diastolic and Systolic CHF
DISEASE
(EF 30-35%)
Type 2 diabetes
DISEASE
Hypertension
DISEASE
Hypercholesterolemia
DISEASE
Chronic Back Pain
DISEASE
degenerative neurological disease
DISEASE
Admission Date: [**2161-2-2**] Discharge Date: [**2161-2-26**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 5438**]Chief Complaint:
hypotension
DISEASE
mental status changes
respiratory distress/failure
DISEASE
Major Surgical or Invasive Procedure:R-sided Femoral lineR-PICCTracheostomyPleurex Catheter Placed-L sidedHistory of Present Illness:[**Age over 90 **] yo M with hx of
hypothyroidism Afib
DISEASE
CAD
HTN
DISEASE
new diagnosisof GE
junction lymphoma
DISEASE
(s/p 3 months of radiation therapy with
tumor
DISEASE
size [**1-5**] as before but now no longer candidate forradiation therapy) who presents from [**Hospital 100**] Rehab with call0inwith
tachypnea
DISEASE
RR 40's with frequent suctioning of very thickmucous..Came from [**Hospital 100**] Rehab with complaints of SOB and DOE. He gotMorphine 8mg po x 1 at [**Hospital 100**] Rehab prior to transfer andsubsequently developed mental status changes. On arrival he wasnoted to have temp 101 BP 70/p HR 120's RR6 99% on 100% NRB.He was given IVF wide open 2mg
Narcan
DISEASE
with Admission Date: [**2161-3-7**] Discharge Date: [**2161-3-10**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 3984**]Chief Complaint:Change in MSMajor Surgical or Invasive Procedure:femoral line placement PICC line placement [**3-8**]History of Present Illness:Patient is a [**Age over 90 **] yo vent dependent male with hx of
hypothyroid
DISEASE
cad s/p cabg ef 45% htn ge
junction lymphoma
DISEASE
who presentsfrom [**Hospital 100**] rehab for change for
tachypnea
DISEASE
and
tachycardia
DISEASE
whilerecieving 1 u prbc for hct 24.4. He was given lasix and foundto have new lbbb on ekg. He was also found to be
febrile
DISEASE
100.4. He was started on levoflox..He was
febrile
DISEASE
in the ED to 102.8 HR 90 and was initiallynormotensive 129/66 however a few hours later became
hypotensive
DISEASE
(of note had rec'd 2mg iv morphine and 40 mg oflasix at that time). Patient was started on the
sepsis
DISEASE
protocolbut in the setting of profound
hypotension
DISEASE
a femoral line wasplaced. Blood and urine cultures were obtained and patient wasgiven vanc levo flagyl. He was also given hydrocortisone andlevophed.Past Medical History:
Hypothyroidism
DISEASE
CAD s/p MI [**2142**] EF 45%
HTN
DISEASE
BPH
Depression
DISEASE
High cholesterol GE
Junction lymphoma
DISEASE
(s/p 3 months ofradiation therapy with
tumor
DISEASE
size [**1-5**] as before but now nolonger candidate forradiation therapy) peripheral T cell lymphomaSocial History:Moved from [**Country 532**] 10 years agoformer engineerwife with
alzheimer's disease
DISEASE
lives alone walks with caneNo ETOH tobaccohis baseline activity -At baseline does not walk. Speaks in full conversations but haslapses of memory at times.Family History:No h/o CADPhysical Exam:Vitals: T BP 100/63 HR 59 afib 100% on AC rr 10 tv 500Gen: ill appearing male in no app. resp distressHEENT: trach opens eyes perrlaLungs: bibasilar cracklesHeart: s1 s2 irreg irregAbd: soft peg tube in placeExt: 2Admission Date: [**2117-3-4**] Discharge Date: [**2117-3-10**]Service: SURGERY
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 4691**]Chief Complaint:Right upper quadrant
pain
DISEASE
Major Surgical or Invasive Procedure:[**2117-3-4**]Laparoscopic cholecystectomyHistory of Present Illness:This is a [**Age over 90 **]M with a history of
DM2
DISEASE
presenting with severeRUQ since last night. He's actually had intermittent mild
pain
DISEASE
x9 days (Admission Date: [**2132-12-8**] Discharge Date: [**2132-12-14**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2387**]Chief Complaint:
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:cardiac catheterizationHistory of Present Illness:Ms [**Known lastname 5448**] is an 89yo pt with h/o CAD s/p RCA stent in [**2124**]a-fib on warfarin and dofetilide who presented to OSH on[**2132-12-7**] with
CHF
DISEASE
exacerbation. BNP was 326 (1-100). CT ruledout PE but showed extensive metastatic disease to pleura.Initial tropI was negative but the 2nd tropI was positive at1.43 at 7AM and 1.79 at 12:30PM. EKG showed e/o possible priorseptal
infarct
DISEASE
no acute ST changes. Cardiology saw her and feltthat given her age and
comorbidity (breast cancer
DISEASE
w/mets) sheis not suitable for further intervention and recommended medicalmanagement. Pt was started on nitro patch. However her primarycardiologist (Dr. [**Last Name (STitle) **] felt otherwise and was willing to cathher so she was transferred to [**Hospital1 18**] for catheterization. Perreport she had an episode of
chest pain
DISEASE
that responded to nitrothis afternoon. Also after speaking with medical team at OSHthe discussion was had about her code status and decision wasmade DNR..At home pt reports passing out 5 days ago. She was getting intobed felt SOB lost consciousness for a couple of minutes. Shereports hitting her head on the left side of her forehead on athick rug. Her sons were with her. Episode of SOB while watchingTV as well as Admission Date: [**2115-11-6**] Discharge Date: [**2115-11-26**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4282**]Chief Complaint:
Hypotension
DISEASE
Major Surgical or Invasive Procedure:CyberKnife mappingHistory of Present Illness:Dr. [**Known lastname 5459**] is an 85 year old gentleman with history of
COPD
DISEASE
on6L home O2 (FEV1 28% predicted) recurrent
DVT
DISEASE
on coumadin andrecently diagnosed LUL
NSCLC
DISEASE
who is admitted with
hypotension
DISEASE
.Today he was scheduled for LUL fiducial electrode placement andwas noted to have relative
hypotension
DISEASE
with [**Name (NI) 5462**] in the 90's..His primary oncologist noted L Admission Date: [**2115-2-7**] Discharge Date: [**2115-2-12**]Date of Birth: [**2056-11-8**] Sex: MService: CARDIOVASCULARCHIEF COMPLAINT: Persistent
chest pain
DISEASE
.HISTORY OF PRESENT ILLNESS: The patient is a 58 year-oldCaucasian male with a past medical history significant for
coronary artery disease
DISEASE
status post four vessel coronaryartery bypass graft in [**2106**] who underwent evaluation ofchest and upper arm discomfort times several weeks. Inaddition the patient was also experiencing
exertional
DISEASE
chest
pain
DISEASE
and
dyspnea
DISEASE
on exertion after one flight of stairs. On[**2115-1-10**] the patient underwent an ETT thallium andexercise for seven minutes by [**Doctor First Name **] protocol with
chest pain
DISEASE
but no significant EKG changes on a normal thallium study.The patient was admitted to the CMI Service on [**2115-2-7**]and underwent coronary catheterization that same day. Duringthis catheterization LV gram revealed a sustained ejectionfraction at 60% with evidence of a 70% proximal and 50% midstenosis of the
SVT
DISEASE
to PDA graft and a 30% proximal stenosisof the SVG to OM2 graft as well as a 99% proximal stenosis ofthe SVG to D1 graft.The patient underwent PTCA and stent placement with noresidual stenosis of the SVG to D1 graft on the 8th with nocomplications at that time. Notably the patient also waswith a patent LIMA to LAD graft during his firstcatheterization. On the [**2-8**] the patient returned tothe catheterization laboratory and underwent a percu-surgedevice procedure for the SVG to PDA lesion. Notably thisartery had diffuse disease proximally with 80% ulceratedstenosis and 40% mid stenosis. The patient underwent PTCAand stent with observation of TIMI-2 fast flow. Thisprocedure was complicated by evidence of distal embolizationof the
plaque
DISEASE
during the procedure. Hemodynamic monitoringat this catheterization revealed RA pressure of 7 pulmonarycapillary wedge pressure of 7 cardiac index of 2.5 with apatent SVG to D1 stent. The patient was kept on Integrilinwith a goal of 48 hours total therapy secondary to hiscomplicated catheterization.Several hours after his second cath on [**2-8**] the patienthad an acute drop in his systolic blood pressures to the70's. He responded with elevation of pressures after 500 ccIV fluid bolus. Telemetry also showed three episodes of fivebeat nonsustained
ventricular tachycardia
DISEASE
. On the morning ofthe 10th the patient was complaining of pleuritic
chest pain
DISEASE
and mild
shortness of breath
DISEASE
. CKs at this time were checkedand were notably rising compared to the prior day. EKG atthis time revealed ST segment elevation of .5 to 1 mm in lead3 AVF and precordial lead V2 to V4 ST depressions. Later inthe evening the patient continued to have constant
chest pain
DISEASE
associated only with
shortness of breath
DISEASE
. The
pain
DISEASE
improvedin the semi-upright position however the patient hadminimal relief with increasing of an IV nitroglycerin drip ormorphine. After consultation of the interventionalcardiology fellow it was believed that the patient was likelyhaving a subacute
myocardial infarction
DISEASE
as indicated byischemic changes on EKG and persistent chest discomfort postcath in the setting of a complicated catheterization withevidence of distal embolization. It was the impression ofthe staff interventional cardiologist that the patient wasnot suitable to take back to the catheterization laboratorysince there was no suitable therapy for small vessel distalembolization. The patient was transferred to the CoronaryCare Unit at this time for hemodynamic monitoring and forclose observation.PAST MEDICAL HISTORY: 1. Coronary
artery disease
DISEASE
statuspost four vessel coronary artery bypass graft in [**2106**] with aLIMA to LAD graft SVG to OM2 SVG to D1 and SVG to PDA. 2.
Hypercholesterolemia
DISEASE
. 3. Hypertension. 4. History oftobacco use.ALLERGIES: The patient has no known
drug allergies
DISEASE
.MEDICATIONS ON TRANSFER: 1. Aspirin 325 mg po q day. 2.Plavix 75 mg po q.d. 3. Zestril 5 mg po q.d. 4.Hydrochlorothiazide 12.5 q day. 5. Lipitor 10 mg po q.d.6. Meclozine 12.5 t.i.d. 7. Integrilin at 15 cc per hourtimes 48 hours. 8. IV nitroglycerin drip. 9. Percocetprn. 10. Morphine sulfate prn.SOCIAL HISTORY: The patient works in home room modeling andconstruction. Occasional social alcohol use. He does notparticipate in any formal exercise program. He is marriedand has grown children. Tobacco history as above. Thepatient is a former smoker.PHYSICAL EXAMINATION: Vital signs on transfer temperature101.4. Pulse 122. Blood pressure 100/45. Pulse 110.Respirations 18. O2 saturation is 100% on 2 liters. 24 hourI and O are 11 35 and over 24 25 outs. General the patientis a well appearing Caucasian male in no acute distress.HEENT head is normocephalic atraumatic. Sclera andconjunctiva are anicteric. Oropharynx is clear without
erythema
DISEASE
or
exudate
DISEASE
. Neck is without evidence of JVD andsupple without obvious
lymphadenopathy
DISEASE
. Chest is clear toauscultation bilaterally. Cardiovascular examination revealsa normal S1 S2
sinus tachycardia
DISEASE
with a questionablepericardial rub and 2Admission Date: [**2120-7-22**] Discharge Date: [**2120-7-25**]Date of Birth: [**2056-11-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1145**]Chief Complaint:
chest pain
DISEASE
Major Surgical or Invasive Procedure:cardiac cathHistory of Present Illness:63 year-old M with CAD s/p CABG ([**2106**] - LIMA to LAD SVG to OM2SVG to D1 SVG to PDA) s/p PTCA ([**2114**] - stents placed to SVG toD1 graft and SVG to PDA graft) who presented with
chest pain
DISEASE
toOSH transferred here for cardiac cath now s/p cath. He awokefrom sleep at home with 8/10
chest pain
DISEASE
L arm discomfort and
diaphoresis
DISEASE
. No SOB or
nausea
DISEASE
. He arose and felt lightheadedand proceeded to have a
syncopal
DISEASE
event. No
trauma
DISEASE
. He went tothe OSH ED at 2 am for evaluationAdmission Date: [**2172-3-1**] Discharge Date: [**2172-3-9**]Date of Birth: [**2117-3-16**] Sex: FService:HISTORY OF PRESENT ILLNESS: This is a 54-year-old whitefemale with a history of
hypertension
DISEASE
and diet controlled
diabetes mellitus
DISEASE
and possible systemic
lupus erythematosus
DISEASE
.Several hours prior to admission the patient noted a sinus
type headache
DISEASE
with
tightness
DISEASE
in the frontal area nose eyesand took sinus medications without relief. The
headache
DISEASE
persisted and she also developed associated
neck pain
DISEASE
andbilateral shoulder. She found it difficult to sleep. Shetook some Tylenol and still had no relief and subsequent tothis the patient
headache
DISEASE
persisted and she presented to theEmergency Room with persistent
headache
DISEASE
and was found to havedifficulty remembering whether the
headache
DISEASE
had come onsuddenly and denied any associated
nausea vomiting
DISEASE
diarrhea constipation weakness
DISEASE
or
further numbness
DISEASE
orneurologic symptoms.PREVIOUS MEDICAL HISTORY: History of
low back pain
DISEASE
historyof
hypertension
DISEASE
times ten years history of
noninsulin
DISEASE
dependent diet controlled
diabetes
DISEASE
history of a tuballigation and a past history of
migraine headaches
DISEASE
.CURRENT MEDICATIONS: Zestril 20 mg q.d. nifedipine 30 mgq.d. and Prempro 2.5 mg q.d.ALLERGIES: She has an
allergic history reaction
DISEASE
topenicillin.SOCIAL HISTORY: She works as a administrative assistant atthe [**Hospital6 256**].FAMILY HISTORY: Positive for
sarcoid
DISEASE
in her mother.PHYSICAL EXAMINATION: The patient was noted to be a healthybut obese female in no acute distress. Neurological examshows awake alert and oriented times three with fluent
speech normal language
DISEASE
and comprehension. Pupils equalround and reactive to light and accommodation. Extraocularmovements intact and visual fields were full toconfrontation. The face was symmetric and sensation wasintact to light touch. The tongue and uvula were midline andthe remainder of the cranial nerve exam was unremarkable.Reflexes were 2Admission Date: [**2190-6-12**] Discharge Date: [**2190-6-15**]Date of Birth: [**2146-5-23**] Sex: MService: MEDICINE
Allergies
DISEASE
:PercocetAttending:[**First Name3 (LF) 896**]Chief Complaint:Alcohol IntoxicationMajor Surgical or Invasive Procedure:Endoctrachial intubationHistory of Present Illness:44 y.o. male with history of numerous ED visits (6 ED visitssince [**2189-3-11**]) for alcohol intoxication presents via [**Location (un) 86**]EMS from local neighborhood attempting to get on publictranportation. Pint of vodka was found on pt and states Admission Date: [**2161-3-19**] Discharge Date: [**2161-3-30**]Service: MEDICINE
Allergies
DISEASE
:Codeine / Penicillins / Sulfa (Sulfonamides)Attending:[**First Name3 (LF) 4028**]Chief Complaint:
Rectal bleeding
DISEASE
Major Surgical or Invasive Procedure:-Angiography-Subclavian cordis / left subclavian central line placed [**3-21**]removed [**3-23**]-ColonoscopyHistory of Present Illness:Mrs. [**Known lastname 5480**] is a [**Age over 90 **]-year-old female with a PMH significantfor
Celiac Disease hemorrhoids
DISEASE
old
CVA
DISEASE
([**2153**])
hypertension
DISEASE
hypothyroidism
DISEASE
and known
cecal AVM
DISEASE
who was recently admitted to[**Hospital3 **] ([**3-14**]) with a large
GIB
DISEASE
5 days prior to thisadmission. At that time her Hct was 19 NGL negative transfusedseveral units of blood to bring her Hct up to 35. No colonoscopyperformed given her overall good clinical stability anddiscussion about risks/benefit of procedure. Patient wasdischarged home yesterday and was doing well until the day ofadmission to this hospital when she had several episodes ofBRBPR associated with
lightheadedness
DISEASE
but no CP/SOB. Alsocomplained of some lower
abdominal cramping
DISEASE
discomfort that wasat worse [**5-3**] in severity and felt better after having a bowelmovement. Bleeding occurred in the setting of her bowelmovements. She had been on Aggrenox for an old
CVA
DISEASE
but this washeld in the middle of [**Month (only) 958**] several days before her lastadmission..Patient has a history of
LGIB
DISEASE
in [**2158**] found to have large
AVM
DISEASE
on
c-scope
DISEASE
that was clipped. No subsequent scopes or
bleeding
DISEASE
until now..In the ED initial vitals: 98.4 89 152/71 18 96%
RA
DISEASE
. The Hctwas 36.5. On rectal exam by ED resident hemorrhoids were notedand there was BRB in the vault but no active source seen. GI wasconsulted. Three PIVs (two 16g and one 18g)were placed and thepatient was typed and crossed by blood bank for 4 units PRBCs..On arrival in MICU she had no complaints and appeared fairlystable. On further ROS at time of admission she denied chest
pains dyspnea
DISEASE
fevers/chills
nusea vomiting diarrhea
DISEASE
.Past Medical History:
Celiac Disease
DISEASE
CVA / Right thalamic capsular stroke with resultant left sided
Ataxic hemiparesis
DISEASE
[**8-26**]
HTN
DISEASE
Glaucoma
DISEASE
L eye
Hypothyroidism
DISEASE
Hyperlipidemia
DISEASE
Restless
DISEASE
legs
OA
DISEASE
Diverticulitis
DISEASE
Fe-deficiency
anemia
DISEASE
Osteoporosis
DISEASE
Borderline pulm
HTN
DISEASE
LGIB
DISEASE
in [**2158**] found to have large
AVM
DISEASE
in the cecum on
c-scope
DISEASE
that was clippedSocial History:Lives in [**Location (un) 5481**] retirement facility. She is a widow andhas one son who lives close by and is very involved with hercare. Denies alcohol drugs or smoking. Extremely independentat baseline with her ADLs IADLs prior to this admission.Family History:No known h/o CA
blood disorders GI disorder
DISEASE
Physical Exam:PHYSICAL
EXAM
DISEASE
ON ADMISSION TO MICU :VS T 96.1F HR 85 BP 130/65 RR 17 Oxygen saturation 94% onroom airGen: Elderly female in NAD pleasant & conversantHEENT: PERRL anicteric MMMHeart: s1s2 RRRPulm: Scattered rhonchiAbd: Admission Date: [**2147-6-24**] Discharge Date: [**2147-7-1**]Service: ICUHISTORY OF PRESENT ILLNESS: The patient is an 84 year-oldfemale admitted with mental status changes. She is an elderlywoman who was institutionalized at a nursing home for thepast two months with a history of
Crohn's disease
DISEASE
who wasadmitted with a
Crohn's
DISEASE
flare and
diarrhea
DISEASE
on [**2147-6-24**].Additionally she was noted to be more lethargic then usual.PAST MEDICAL HISTORY:
Crohn's disease
DISEASE
hypertension
DISEASE
diverticulitis osteoarthritis
DISEASE
palpable deep venous
thrombosis
DISEASE
urinary tract infection.MEDICATIONS: Celexa folate Pentasa Ritalin Nadolol.ALLERGIES: Penicillin.FAMILY HISTORY: No history of
IBD
DISEASE
.SOCIAL HISTORY: Nursing home resident.PHYSICAL EXAMINATION: Blood pressure 109/52. Chest clear toauscultation. Abdomen guaiac negative diffusely firmabdomen.HOSPITAL COURSE: The patient is an 84 year-old woman with
inflammatory bowel disease
DISEASE
admitted with
hypotension
DISEASE
dehydration
DISEASE
acute renal failure
DISEASE
and
urinary tract infection
DISEASE
.The patient was treated aggressively for the above issues.Specifically for
sepsis
DISEASE
and
Crohn's
DISEASE
flare. She continued tohave a low blood pressure during her hospital stay and wasput on blood pressure supporting medication. She was treatedon antibiotics for her
sepsis
DISEASE
and she was treated withMethylamine and Protonix for her
Crohn's
DISEASE
flare. Despitethese efforts the patient continued to deteriorate clinicallyand family meetings were held to keep the family aware of herpoor prognosis. On [**2147-7-1**] at 6:01 a.m. the patientexpired despite aggressive fluid and pressor support. Herniece [**Name (NI) 1894**] [**Name (NI) 805**] was notified.FINAL DIAGNOSES:1. Crohn's flare.2.
Sepsis
DISEASE
. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1895**] M.D. [**MD Number(1) 1896**]Dictated By:[**Last Name (NamePattern1) 1897**]MEDQUIST36D: [**2147-8-28**] 17:02T: [**2147-9-5**] 06:59JOB#: [**Job Number 1898**]Admission Date: [**2175-1-29**] Discharge Date: [**2175-2-4**]Date of Birth: [**2089-2-21**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 1145**]Chief Complaint:
shortness of breath and chest pain
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:85 year old man with
CAD chronic systolic CHF
DISEASE
EF40%
HTN
DISEASE
HLDCKD
peripheral vascular disease
DISEASE
presents with shortness ofbreath and
chest pain
DISEASE
. Pt states that two days ago he developedsome CP pain and sob. He took ntg with resolution of CP howeverthe sob got progressively worse. He felt that he had a Admission Date: [**2100-7-16**] Discharge Date: [**2100-8-12**]Service: NEUROLOGY
Allergies
DISEASE
:BactrimAttending:[**First Name3 (LF) 618**]Chief Complaint:Left sided weakness neglect and global
aphasia
DISEASE
Major Surgical or Invasive Procedure:Endotracheal IntubationHistory of Present Illness:History obtained from speaking with the patient's family andreview of OMR.Ms. [**Known lastname 5021**] is a 89 year-old right-handed [**Known lastname 595**] speaking womanwith past medical history significant for
hypertension anemia
DISEASE
hypothyroidism chronic renal insufficiency renal cell cancer
DISEASE
s/p right nephrectomy and
left frontal stroke
DISEASE
in [**2100-5-11**] withno residual deficits who presents with left sided weaknessneglect and
aphasia
DISEASE
. She was first found this morning at 1030hrson [**2100-7-16**] on the floor by her husband. It was unknown howlong she was down for.At that time she was able to communicate and said she couldn'thear or see well. She did say that she tripped and fell and thatwas why she was on the floor. She was also confused when she wasfoundAdmission Date: [**2123-4-6**] Discharge Date: [**2123-4-9**]Date of Birth: [**2081-1-14**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2009**]Chief Complaint:
seizure
DISEASE
Major Surgical or Invasive Procedure:intubationHistory of Present Illness:Patient is a 42 year-old male with past medical historysignificant for
alcoholism
DISEASE
and
depression
DISEASE
. Patient presented toED earlier this evening complaining of having fell off of a poleand fell backwards [**Location 5491**]in [**Location (un) 86**]. He had a scalplaceration which was not initially able to be repaired due to
c-spine
DISEASE
precautions. The patient had a head CT which wasnegative for any
intracranial bleeds
DISEASE
. CT neck also negative forany
fractures
DISEASE
.In the ED initial vs were: T P 88 BP 89/58 RR 14 and O2 sat100%
RA
DISEASE
. While in the ED the patient appeared anxious andconfused initially. ETOH level was 105 and the rest oftoxicology screen was negative..In the ED he then had a witnessed
apneic
DISEASE
episode and then wentunresponsive for a few seconds per ED resdient but he had apalpable pulse and blood pressures remained stable. During thisepisode he had dropping oxygen saturations (drop not recorded)and he was clinching his jaw to the point where he chipped histooth. Patient then went into rapid bilateral upper extremity
myoclonic jerking
DISEASE
followed by partial proning of his armsbilaterally. He was given Ativan 2mg IV x2 then 5mg IV Ativanthen 6mg IV Ativan followed by 7mg IV Ativan in ED..Minutes later he developed
SVT
DISEASE
to 200 range which appeared to be
atrial fibrillation
DISEASE
vs.
flutter
DISEASE
per ED resident. He wasintubated rapidly and then cardioverted in the ED with goodresponse as HR returned to NSR with rate in 70-90 range..EKG was significant for borderline long QRS at .122 as well.Toxicology was called and suggested patient be given bicarbonatefluid to cover for possible
TCA overdose
DISEASE
given EKG findings.While in ED he was given tetanus shot given new scalplaceration 3L NS IVFs and then 3Amps bicarbonate were given inD5. He also got 1g IV Dilantin load and he was placed onPropofol and a Versed drip started after intubation..On arrival to the MICU patient was intubated and sedated. He wason AC mode with Tv 600 x RR 16 FiO2 40% and PEEP 5. HR was 90BP 132/88 and patient was afebrile. He had dry dressings packedover right sided
head laceration
DISEASE
and he was in a
c-spine
DISEASE
collar.Past Medical History:-alcoholism-depressionSocial History:Unable to obtain as intubated sedatedFamily History:NCPhysical Exam:Vitals: AC mode with Tv 600 x RR 16 FiO2 40% and PEEP 5.saturations 100%. HR 90 BP 132/88 Temp 99.9 F.General: sedated intubated pale skin very warmHEENT: Sclera anicteric MMM oropharynx with some evidence ofdried blood over right buccal mucosaSkin: pale skin scalp with right posterior laceration crusted
dry blood
DISEASE
over hair about 1Admission Date: [**2132-9-17**] Discharge Date: [**2132-9-26**]Service: MEDICINE
Allergies
DISEASE
:Histamine H2 Inhibitors / Codeine / Sulfa (SulfonamideAntibiotics) / Proton Pump Inhibitors / Penicillins / DemerolAttending:[**First Name3 (LF)
3705
DISEASE
**]Chief Complaint:HypoxiaMajor Surgical or Invasive Procedure:noneHistory of Present Illness:Ms. [**Known lastname 5501**] is a [**Age over 90 **] year-old woman with a history of
Parkinson's CAD dilated CM
DISEASE
(EF 30%) chronic mesentericischemic s/p stents recent fall complicated by humeral
fracture
DISEASE
aspiration
pneumonia
DISEASE
. Please see admission note forfull details of history. Briefly she was admitted to OSH [**9-9**]with aspiration
pneumonia
DISEASE
. She was treated with broad spectrumantibiotics but decomepensated with [**Last Name (un) **] demand
ischemia
DISEASE
concern for new
mesenteric ischemia
DISEASE
. She was transferred fromOSH ICU to [**Hospital1 18**] ICU on [**9-17**]..In the ICU she was hemodynamically stable without oxygenrequirement. Vancomycin and levofloxacin (needs 6 more days tocomplete 10 day course) were started. PICC was placed.Aspiration was thought to be in part secondary to compromisedmental status from polypharmacy. Zyprexa was given becausepatient was moaning resulting in BP drop to the 80s. EKG showedlateral TW changes thought to be secondary to demand. Plavixwas held.Past Medical History:* Cardiac Risk Factors: (-)Diabetes (Admission Date: [**2166-12-9**] Discharge Date: [**2166-12-12**]Date of Birth: [**2094-11-9**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1666**]Chief Complaint:
Loss of consciousness
DISEASE
Major Surgical or Invasive Procedure:Hemodialysis.Intubation.History of Present Illness:72 year old man with stage 4
CKD
DISEASE
on
HD
DISEASE
CAD
HTN asthma
DISEASE
whopresented with multiple falls and was found by EMS to be in awide complex brady to 20 bpm with BP of 50 systolic. Per wifeand friend pt was in USOH until day prior to admission when hestarted to feel shaky &
tremulous
DISEASE
hands. Gait somewhat unsteadyw/ generalized weakness. Has not had any fevers/chills/sweatsno
diarrhea
DISEASE
no CP/palpitations/SOB.On morning of admission pt went shopping w/friend upon leavingstore pt was very nauseated Admission Date: [**2169-8-9**] Discharge Date: [**2169-8-12**]Date of Birth: [**2094-11-9**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 425**]Chief Complaint:
Bradycardia
DISEASE
(slow heart rate)Major Surgical or Invasive Procedure:Implantation of a Pacemaker ([**Company 1543**] VDD type single lead)History of Present Illness:Mr. [**Known firstname 1975**] [**Known lastname 5512**] is a 74 yo [**Known lastname 595**]-speaking male with
ESRD
DISEASE
on
HD
DISEASE
h/o mild CAD
hypertension dyslipidemia
DISEASE
diastolicdysfunction who presented to hemodialysis today and was foundto be bradycardic. He completed hemodialysis without anycomplications and had 2.5L of fluid removed. He had a heartrate of Admission Date: [**2169-12-31**] Discharge Date: [**2170-1-5**]Date of Birth: [**2094-11-9**] Sex: MService: [**Year (4 digits) 662**]
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 800**]Chief Complaint:altered mental statusMajor Surgical or Invasive Procedure:Femoral line placedHistory of Present Illness:75 y/o M [**First Name3 (LF) **] speaking only PMH
ESRD
DISEASE
on
HD
DISEASE
CAD PAF
COPD
DISEASE
HTN
DISEASE
who presensts with altered mental status of 2 days duration.Initially felt to be secondary to percocet use at rehab but HDfacility was concerned and sent patient to be evaluated. Perfamily patient is AOx3 at baseline but has been more confusedrecently. Notes slow decline over several days since being atthe rehab. States he was also given a Admission Date: [**2114-6-14**] Discharge Date: [**2114-6-20**]Date of Birth: [**2041-10-5**] Sex: FService: NEUROSURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1835**]Chief Complaint:
incontinence/lower extremity pain/weakness
DISEASE
Major Surgical or Invasive Procedure:Posterior cervical laminectomyDecompressive lumbar laminectomyHistory of Present Illness:72-year-old woman who has a history of mildmental retardation who lives and works in a monitored caresetting. She has a complex past medical history including adistant
left frontal meningioma
DISEASE
resection as well as a previousanterior cervical discectomy with fusion in [**2107**] by Dr. [**Last Name (STitle) 1338**](
C4-C7
DISEASE
). The patient is unable to recall the majority of herpast medical history. She now presents with progressive urinary
incontinence
DISEASE
and
fecal incontinence
DISEASE
. Urinary incontinence wasnoticed for at least a year. Fecal
incontinence
DISEASE
seems to bepresent for about 3-4 weeks only. The patient has in additionfelt a decrease in her ability to walk but is mobile with awalker. She complains about bilateral lower extremity
paresthesias
DISEASE
left greater than right. She has intermittentbilateral
upper extremity numbness
DISEASE
. She also complains aboutprogressive right-sided
thigh pain
DISEASE
when she is going down thestairs. She walks with awalker. The patient takes home medications includinghydrochlorothiazide Protonix Fosamax and naproxen. She isnotknown to have any
drug allergies
DISEASE
. She is a nonsmokernondrinker.Past Medical History:The patient has a past medical history that is relevantfor
hypertension
DISEASE
GERD
osteoporosis
DISEASE
. Surgical history remainsrelevant for a distant
left frontal meningioma
DISEASE
resection statuspost ACDF
C4-C7
DISEASE
in [**2107**] and a right-sided THR.Social History:The patient takes home medications includinghydrochlorothiazide Protonix Fosamax and naproxen. She isnotknown to have any
drug allergies
DISEASE
. She is a nonsmokernondrinker.Family History:noncontributoryPhysical Exam:Physical examination reveals that she is awake and alert andinteractive. She is slightly retarded and slow but pleasantlyinteractive. She walks into the office with a walker. She hasan obvious
kyphosis
DISEASE
but is more mobile with a walker and showsno signs of imbalance. The cranial nerves are remarkable for aprominent right-sided exotropia at rest. Bilateral pupils arereactive to light and accommodation.
Extraocular movements
DISEASE
arefull despite disconjugate gaze. There is no
nystagmus
DISEASE
. She hasgood visual fields. Facial strength and sensation are normal.Hearing is intact. Tongue is midline and shows no signs of
atrophy
DISEASE
of
fasciculation
DISEASE
. Motor exam is somewhat limited butshows mild to moderate
wasting
DISEASE
of hand intrinsic muscles as wellas thenar. Tone is increased in both legs with signs of
spasticity
DISEASE
. She has
weakness
DISEASE
in the distal upper extremityapproximately [**5-2**] bilaterally. She has good strengthapproximately bilaterally except the right-sided deltoid. Shehas bilateral
lower extremity weakness
DISEASE
4/5 with more prominentweakness in the toe bilaterally. Fine motor control is nottestable. She has no drift. Sensory exam reveals no obviousdeficits bilaterally. She complains about
dysesthesias
DISEASE
in anonradicular pattern. Symmetric reflexes were elicited. Shehasbilateral upgoing toes.Pertinent Results:[**2114-6-14**] 08:30PM WBC-12.5* RBC-3.29* HGB-10.3* HCT-29.1*MCV-88 MCH-31.3 MCHC-35.4* RDW-14.1[**2114-6-14**] 08:30PM PLT COUNT-224[**2114-6-14**] 08:00PM CK(CPK)-136[**2114-6-14**] 08:00PM
CK-MB-9
DISEASE
cTropnT-Admission Date: [**2186-1-13**] Discharge Date: [**2186-1-20**]Date of Birth: [**2126-12-12**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 613**]Chief Complaint:
Acute Renal Failure
DISEASE
Major Surgical or Invasive Procedure:
HD
DISEASE
line placementHistory of Present Illness:59 y/o M w/ h/o
hepatitis C HTN CKD
DISEASE
with baseline Cr of 2.0.Patient had been having 2 weeks of
fatigue fever chills
DISEASE
dysuria
DISEASE
with
watery stools
DISEASE
and decreased PO intake. Had beenessentially bed bound. By Sunday was able to get out of bed andon Tuesday visited his PCP who found to have Cr of 20 and BUN of120. Was brought in for repeat labs which confirmed initialfindings and then referred to ED for evaluation..In the ED initial vs were: T98.8 P83 BP 161/102 R 18 O2 sat 93%
RA
DISEASE
. SBP of 220/125 at maximum during ED stay. Exam notable fordiminished breath sounds. LUQ
TTP
DISEASE
on exam. Asterixis and coarse
tremor
DISEASE
on exam. CXR - LLL infiltrate with mild to moderatecongestion. Treated with lasix as per Renal with 250cc urineoutput. Azithromycin/CTX for
pneumonia
DISEASE
. Renal planned tocontinue diuresis and consider HD. Vitals on transfer HR 84 BP180/100 RR 21 O295% 2L..On arrival patient was c/o mild LUQ
pain
DISEASE
that had been presentfor some time..Review of sytems:(Admission Date: [**2118-2-6**] Discharge Date: [**2118-2-16**]Date of Birth: Sex:Service:CHIEF COMPLAINT: Initially admitted for complaints of
shortness of breath
DISEASE
.HISTORY OF PRESENT ILLNESS: This is a 72 year old femalewith a history of
chronic obstructive pulmonary disease
DISEASE
hypertension
DISEASE
hyperlipidemiaAdmission Date: [**2102-2-19**] Discharge Date: [**2102-3-9**]Service: NeurosurgeryHISTORY OF PRESENT ILLNESS: This is a 79-year-old femalewith a history of
atrial fibrillation
DISEASE
on Coumadin
hypertension
DISEASE
and
cerebellar cerebrovascular accident
DISEASE
whopresented to the Emergency Department complaining of
nausea
DISEASE
no
vomiting
DISEASE
and
headache
DISEASE
since one night prior to admission.When the patient woke up this morning the patient hadprogressive
dysarthria
DISEASE
. The patient denied any visual orauditory changes. The patient also denied any
fevers
DISEASE
chills
DISEASE
changes in
bowel habits chest pain shortness
DISEASE
of
breath melena
DISEASE
bright red blood per rectum and
hematemesis
DISEASE
.PAST MEDICAL HISTORY: 1.
Hypertension
DISEASE
. 2. Atrial
fibrillation
DISEASE
. 3.
Cerebrovascular accident
DISEASE
.MEDICATIONS AT HOME: 1. Atenolol. 2. Coumadin. 3. Plendil.4. Lipitor. 5. Avapro. 6. Neurontin. 7. Hydralazine.ALLERGIES: 1. Codeine. 2. Macrodantin.PHYSICAL EXAMINATION: The patient's temperature was 96.8pulse 71 blood pressure 206/110 respiratory rate 16 oxygensaturation was 94% on room air. The patient was alert andoriented x 3 in no acute distress. The patient's speech wasdysarthric. The patient's pupils were equal round andreactive to light. The patient's
extraocular movements
DISEASE
wereintact. The patient had symmetric eyebrow lift andsymmetric smile. The patient had no tongue deviation nopronator drift. The patient had 5Admission Date: [**2119-6-14**] Discharge Date: [**2119-7-1**]Date of Birth: [**2045-3-23**] Sex: FService: MEDICINE
Allergies
DISEASE
:PercocetAttending:[**First Name3 (LF) 562**]Chief Complaint:
cholecystitis
DISEASE
Major Surgical or Invasive Procedure:IntubationCholecystomy Tube placementThoracentesisHistory of Present Illness:74 y/o female with PMH significant for
COPD
DISEASE
CAD and
hypertension
DISEASE
admitted to [**Hospital1 18**] on [**6-14**] to the surgery servicewith two days of epigastric and right upper quadrant
pain
DISEASE
. Shehad also been
febrile
DISEASE
to 101 and had one episode of
nausea
DISEASE
and
vomiting
DISEASE
. Per notes her abdominal exam was significant forepitastric and right upper quadrant tendernessAdmission Date: [**2121-5-30**] Discharge Date: [**2121-7-5**]Date of Birth: [**2055-7-11**] Sex: FService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 5547**]Chief Complaint:
Small bowel obstruction
DISEASE
Major Surgical or Invasive Procedure:ex lap bowel resection [**Doctor Last Name **] ostomy ([**5-30**]) percutaneoustracheotomy CT guided drainage with catheter placement toabdominal fluid collection left sided thoracostomybronchoscopy central line placementHistory of Present Illness:65 y/o F s/p total gastrectomy for signet ring cell gastric
adenocarcinoma
DISEASE
with Roux-en-Y esophagojejunostomy and feedingjejunostomy tube placement presented on POD #10 with acute onsetof
RUQ pain
DISEASE
. Patient had recent swallow study showing noevidence of a leak and had been tolerating a clear liquid/fullliquid diet until presenting to the hospital on [**5-30**]. Patientalso complained of
nausea vomiting fevers
DISEASE
and
chills
DISEASE
. She hadher
last bowel movement
DISEASE
on the morning of admission.Past Medical History:Breast CA s/p hysterectomy and Chemo (adriamycin and tamoxifen)GERD
Hypercholesterolemia
DISEASE
Glaucoma
DISEASE
Physical Exam:CV:
asystole
DISEASE
no heart rhythmResp: no breath sounds no respirations - spontaneous orotherwiseNeuro: pupils dilated to 5mm unreactive to light bilaterallyAdmission Date: [**2111-7-28**] Discharge Date: [**2111-8-11**]Date of Birth: [**2035-7-3**] Sex: MService: SURGERY
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 371**]Chief Complaint:
Vomiting
DISEASE
and abdominal pain/distentionMajor Surgical or Invasive Procedure:[**2111-7-30**]- Sigmoid colectomy[**2111-8-4**]- Exploratory Laparotomy Resection of AnastamosisHartmann's Closure with descending end colostomy[**2111-8-7**]- Right upper extremity PICC line placementHistory of Present Illness:Mr. [**Known lastname 5549**] is a 76 year old male with a history of
CHF HTN
DISEASE
and [**Hospital 5550**] transferred to [**Hospital1 18**] from [**Hospital 100**] Rehab on [**2111-7-28**] with4 days of worsening
abdominal distention
DISEASE
and
feculent vomiting
DISEASE
.He reportedly had not had a bowel movement or passed gas since[**2111-7-24**]. While being transported to the hospital he reportedlyhad a low oxygen saturation to 80%. He denied
fever chills
DISEASE
SOB or CP. In the ED imaging was concerning for large bowel
volvulus
DISEASE
and the patient was admitted to the CSICU under theacute care service for episodes of
desaturation
DISEASE
and furtherworkup of his abdominal symptoms.Past Medical History:-Congestive Heart Failure-Hypertension-Migraines-s/p right hip replacement-Chronic
constipation
DISEASE
-Cataracts-BPH-Depression/Anxiety
-s/p hernia
DISEASE
repairSocial History:Resident at [**Hospital 100**] RehabFamily History:noncontributoryPhysical Exam:Vitals: HR95 BP158/103 RR16 93% on 5LGEN: A&Ox3 NADHEENT: No scleral icterus oral mucous membranes dryCV: RR nl S1/S2 No M/G/RPULM: Clear to auscultation b/l No W/R/RABD: Grossly distended tympanic nontender no rebound orguarding Admission Date: [**2148-5-19**] Discharge Date: [**2148-5-28**]Date of Birth: [**2075-9-2**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 5552**]Chief Complaint:Maroon stoolsMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:Full hx as per ICU admit note. Briefly this is a 72 year oldman with a past medical history significant for metastatic
gastric cancer
DISEASE
(tolerating adriamycin after failing multipleregimens) localized
prostate cancer
DISEASE
bilateral cephalic vein
thromboses
DISEASE
in the setting of coumadin therapy in [**2148-4-9**] and
portacath thrombus
DISEASE
in [**2148-1-11**] who presented with four daysof dark stools and hematocrit drop from 37 to 24 andintermittent
abdominal pain
DISEASE
and
nausea
DISEASE
after being dischargedto nursing facility on [**5-13**] on chronic lovenox therapy..In the ICU the pt underwent an EGD with showed a fungating masswith stigmata of recent
bleeding
DISEASE
of malignant appearance wasfound in the antrum of the stomach. There was an
ulcer
DISEASE
withinthe mass with an adherent clot. The
ulcer
DISEASE
was injected.However after the procedure the patient continued to have
bleeding
DISEASE
and an angiography was performed. The GDA was embolizedwith coils and Gelfoam slurry. Subsequently the patient has beendoing well and no more drop in the hct was noted. He wastransfused a total of 4 U PRBC per the blood bank record thelast one on [**5-20**]..The patient is currently doing well and denies any further
abdominal pain
DISEASE
or
nausea/vomiting
DISEASE
. He reports 2 cream-colored BMtoday..ROS: Otherwise negative for
dysuria CP SOB
DISEASE
. He has been ableto tolerate liquids and solid food. He endorses a
weight loss
DISEASE
of144 to 126 pounds in the last 2 months.Past Medical History:-Gastric
cancer
DISEASE
diagnosed in [**2147-7-11**]Admission Date: [**2130-5-11**] Discharge Date: [**2130-6-2**]Date of Birth: [**2057-7-28**] Sex: FService: SURGERY
Allergies
DISEASE
:Penicillins / Interferons / LatexAttending:[**First Name3 (LF) 668**]Chief Complaint:Altered mental status and hypotension/PneumoniaMajor Surgical or Invasive Procedure:[**2130-5-15**]: Paracentesis[**2130-5-16**]: Orthotopic Liver transplant[**2130-5-23**]: Post pyloric feeding tube placement[**2130-5-23**]: Flexible Bronchoscopy[**2130-5-24**]: Pleural tapAdmission Date: [**2142-8-26**] Discharge Date: [**2142-8-31**]Date of Birth: [**2068-12-5**] Sex: MService: MICU-GREENHISTORY OF PRESENT ILLNESS: The patient is a 73 year oldmale with a recent history of paroxysmal
atrial fibrillation
DISEASE
and
hypercholesterolemia
DISEASE
who presented to the EmergencyDepartment with the chief complaint of
syncope
DISEASE
. The patientwas discharged from [**Hospital1 69**] withthe diagnosis of
pulmonary embolism
DISEASE
about six months prior tothe current admission and was started on Warfarin. One monthprior to this admission the patient reports not feeling wellwith worsening
gastric distress
DISEASE
. A few weeks prior toadmission he fell down on his back and started takingibuprofen 1000 mg once a day for
pain
DISEASE
and Vioxx in additionto his aspirin and Coumadin regimen.The night prior to admission he was found by his wife on thebathroom floor in a pool of urine unresponsive without anybody movements post-ictal state. EMS was activatedhowever the patient refused to go to the hospital. Asimilar episode happened at 2 a.m. the same night and at07:45 on the day of admission the patient lost consciousnessonce again when he was trying to sit up. He was thentransferred to [**Hospital1 69**].The patient reports some
nausea
DISEASE
and epigastric pressure whichis post-prandial. He denies any
emesis melena diarrhea
DISEASE
or
constipation
DISEASE
. He describes the room spinning with attemptsto sit upright. No history of previous episodes was noted.
Denies incontinence
DISEASE
. He does have
diaphoresis
DISEASE
and
weakness
DISEASE
with
orthostatic
DISEASE
changes.In the Emergency Department stool guaiac was trace positive.Hematocrit was 24.8 with a baseline of 46. Gastric lavagewas grossly positive for coffee ground material. His INR wasfound to be 4.4. He was given Vitamin K 10 mgsubcutaneously 2.5 liters of normal saline two units ofpacked red blood cells and two units of fresh frozen plasmaand transferred to the Medical Intensive Care Unit forfurther management.PAST MEDICAL HISTORY:1.
Hyperthyroid disease
DISEASE
status post radioactive iodineablation now
hypothyroid
DISEASE
on Levoxyl.2. History of
pulmonary embolism
DISEASE
etiology unknown. It wasthought to be induced by frequent flying to [**State 108**]. Thepatient was started on Coumadin five months prior to thisadmission.3. Hypercholesterolemia. Well controlled on Lipitor. Lasttotal cholesterol was 168 in [**2142-5-28**].4. Paroxysmal
atrial fibrillation
DISEASE
in the setting of
pulmonary embolism
DISEASE
.PAST SURGICAL HISTORY:1. Only significant for a right inguinal
hernia
DISEASE
repair.ALLERGIES: Penicillin.OUTPATIENT MEDICATIONS:1. Lipitor 10 mg three times a week.2. Aspirin 81.3. Propranolol 10 mg three times a day.4. Coumadin 6.25 mg once a day.5. Levoxyl 100 mEq q. day.6. Ambien p.r.n.7. Vitamins.8. Vioxx times three weeks.SOCIAL HISTORY: The patient quit smoking 20 years agoAdmission Date: [**2142-8-26**] Discharge Date: [**2142-8-31**]Date of Birth: [**2068-12-5**] Sex: MService: MICU-GREENHISTORY OF PRESENT ILLNESS: The patient is a 73 year oldmale with a recent history of paroxysmal
atrial fibrillation
DISEASE
and
hypercholesterolemia
DISEASE
who presented to the EmergencyDepartment with the chief complaint of
syncope
DISEASE
. The patientwas discharged from [**Hospital1 69**] withthe diagnosis of
pulmonary embolism
DISEASE
about six months prior tothe current admission and was started on Warfarin. One monthprior to this admission the patient reports not feeling wellwith worsening
gastric distress
DISEASE
. A few weeks prior toadmission he fell down on his back and started takingibuprofen 1000 mg once a day for
pain
DISEASE
and Vioxx in additionto his aspirin and Coumadin regimen.The night prior to admission he was found by his wife on thebathroom floor in a pool of urine unresponsive without anybody movements post-ictal state. EMS was activatedhowever the patient refused to go to the hospital. Asimilar episode happened at 2 a.m. the same night and at07:45 on the day of admission the patient lost consciousnessonce again when he was trying to sit up. He was thentransferred to [**Hospital1 69**].The patient reports some
nausea
DISEASE
and epigastric pressure whichis post-prandial. He denies any
emesis melena diarrhea
DISEASE
or
constipation
DISEASE
. He describes the room spinning with attemptsto sit upright. No history of previous episodes was noted.
Denies incontinence
DISEASE
. He does have
diaphoresis
DISEASE
and
weakness
DISEASE
with
orthostatic
DISEASE
changes.In the Emergency Department stool guaiac was trace positive.Hematocrit was 24.8 with a baseline of 46. Gastric lavagewas grossly positive for coffee ground material. His INR wasfound to be 4.4. He was given Vitamin K 10 mgsubcutaneously 2.5 liters of normal saline two units ofpacked red blood cells and two units of fresh frozen plasmaand transferred to the Medical Intensive Care Unit forfurther management.PAST MEDICAL HISTORY:1.
Hyperthyroid disease
DISEASE
status post radioactive iodineablation now
hypothyroid
DISEASE
on Levoxyl.2. History of
pulmonary embolism
DISEASE
etiology unknown. It wasthought to be induced by frequent flying to [**State 108**]. Thepatient was started on Coumadin five months prior to thisadmission.3. Hypercholesterolemia. Well controlled on Lipitor. Lasttotal cholesterol was 168 in [**2142-5-28**].4. Paroxysmal
atrial fibrillation
DISEASE
in the setting of
pulmonary embolism
DISEASE
.PAST SURGICAL HISTORY:1. Only significant for a right inguinal
hernia
DISEASE
repair.ALLERGIES: Penicillin.OUTPATIENT MEDICATIONS:1. Lipitor 10 mg three times a week.2. Aspirin 81.3. Propranolol 10 mg three times a day.4. Coumadin 6.25 mg once a day.5. Levoxyl 100 mEq q. day.6. Ambien p.r.n.7. Vitamins.8. Vioxx times three weeks.SOCIAL HISTORY: The patient quit smoking 20 years agoAdmission Date: [**2156-9-14**] Discharge Date: [**2156-10-4**]Date of Birth: [**2116-3-20**] Sex: FService: NEUROLOGY
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 2090**]Chief Complaint:
confusion
DISEASE
Major Surgical or Invasive Procedure:Dialysis on [**2156-9-14**] for
acidosis
DISEASE
and
hypokalemia
DISEASE
IntubationPICC line placementHistory of Present Illness:40-year-old female
DM2
DISEASE
transferred from [**Hospital 1562**] Hospital forsevere
acidosis
DISEASE
from Admission Date: [**2113-6-4**] Discharge Date: [**2113-6-10**]Date of Birth: [**2055-3-17**] Sex: MHISTORY OF PRESENT ILLNESS: This is a 58-year-old male witha 5-year history of a large right lobe cavernous hemangioma.He was admitted to [**Hospital1 69**] on[**5-31**] after experiencing the subacute onset of
fevers
DISEASE
time to have had a
intrahepatic mass bleed
DISEASE
requiring 2 unitsof packed red blood cells. He stabilized and sent home forthe weekend with plans to come back on [**6-4**] to undergo theresection of this
hemangioma
DISEASE
which had now become unstable.PAST MEDICAL HISTORY: Past medical history significant for
hypercholesterolemia
DISEASE
which has since resolved.MEDICATIONS ON ADMISSION: None.ALLERGIES: No known drug
allergies
DISEASE
.PHYSICAL EXAMINATION ON PRESENTATION: Examination at thetime of admission revealed his lungs were clear toauscultation bilaterally. His heart had a regular rate andrhythm. His abdomen was soft nontender and nondistended.His extremities were warm and well perfused.HOSPITAL COURSE: The patient was admitted to the GeneralSurgical Service on [**2113-6-4**]. Initial laboratory valuesat that time demonstrated a hematocrit of 34.2 an alkalinephosphatase of 559 and a total bilirubin of 2. The rest ofhis laboratories were unremarkable.On [**6-5**] the patient underwent an uncomplicated resectionof the
hemangioma
DISEASE
of his right hepatic lobe with minimalresection of the liver parenchyma itself. The patienttolerated the procedure well.Overnight the patient was recovered in the SurgicalIntensive Care Unit predominantly because of a 5.5-liter
blood loss
DISEASE
intraoperative. He remained intubated untilpostoperative day one at which time he was extubated withoutdifficulty.He was transferred to the floor on postoperative day one andhad an uneventful postoperative course thereafter. Hecontinued to have low-grade
fevers
DISEASE
postoperatively but bythe day of discharge had remained afebrile for greater than24 hours.On postoperative day four the patient passed flatus and hada bowel movement and his diet was advanced withoutdifficulty. His urine output had remained more than adequatethroughout his hospital stay. The Foley catheter wasdiscontinued on postoperative day three. His total bilirubinrose to 8 on the day of operation but continued to trenddownward to 2 on postoperative day four. His hematocrit haddropped to 29 postoperatively after resuscitation and bloodproducts. On the day of discharge his hematocrit hasstabilized at around 27. The pathology on the specimen waspositive only for
hemangioma
DISEASE
with areas of
infarct
DISEASE
. He had ablood culture from [**6-6**] that grew out 1/4 bottles positivefor guaiac-negative StaphylococcusAdmission Date: [**2123-10-27**] Discharge Date:Date of Birth: [**2085-3-7**] Sex: MService:HISTORY OF PRESENT ILLNESS: This is a 38-year-old man with
AIDS
DISEASE
referred by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4569**] who has
fevers
DISEASE
to greaterthan 104 likely
pneumonia
DISEASE
or other pulmonary processincreasing for one month. He reports increased
cough
DISEASE
usually nonproductive but occasional production of bloodysputum. In addition he has some dark stool which he statesis maroon in color in the last few weeks as well as
nausea
DISEASE
and
vomiting
DISEASE
. He states that sometimes he
vomits
DISEASE
blood.Reports left upper quadrant
pain
DISEASE
times one month with eating.
Denies dyspnea
DISEASE
or
chest pain
DISEASE
. He states some
pain
DISEASE
in hischest with
cough
DISEASE
only and that's resolved mild
headache
DISEASE
likea hot plate on his forehead mild
neck pain
DISEASE
positive urinaryfrequency and
dysuria
DISEASE
times weeks. Today he has had
diarrhea
DISEASE
30 minutes after meals. He states he has been
depressed
DISEASE
not sleeping and wants to die without active
suicidal ideation
DISEASE
.PAST MEDICAL HISTORY:1. HIV diagnosed in [**2118**] treated with HAART in [**2122-7-2**]viral load was 50000 went to less than 50 but then patientquit his medications after his rectal abscess. Last CD4count [**2123-7-2**] was 1 viral load in [**2123-6-1**] was greaterthan 500000.2. Kaposi's of skin oral cavity and lung status postchemotherapy in [**2119**].3. ......... of the skin buttocks in [**2122-4-1**].4. History of
neutropenia
DISEASE
exacerbated by Bactrim andresolved with discontinuation.5. HSV2 resolved [**2123-6-1**] perianal.6. History of
perianal abscess
DISEASE
in [**2122**] status post surgery.7. Left upper lobe pneumonia in [**2123-7-10**] treated withlevofloxacin and resolved.8. Recurrent
zoster
DISEASE
.9.
Pancreatitis
DISEASE
.10. Oral
ulcers
DISEASE
and [**Female First Name (un) **]
esophagitis
DISEASE
.11.
Depression
DISEASE
.12.
Tinea
DISEASE
barba.SOCIAL HISTORY: 45 pack year of tobacco. Formerly 12-24beers most recently until five days ago.FAMILY HISTORY: Noncontributory.ALLERGIES: Bactrim intolerance.MEDICATIONS: Patient on only one month in [**Month (only) 205**] acyclovir 800t.i.d. times 30 days then b.i.d. azithromycin 250 timesfive q. week dapsone 100 q.d. Epivir 150 b.i.d. Indinavir400 b.i.d. Paxil 20 Prilosec 20 Ritonavir 100 times fourb.i.d. stavudine 40 b.i.d.REVIEW OF SYSTEMS: No
rigors fevers
DISEASE
and
chills
DISEASE
and
sweats
DISEASE
today only.
Weight loss
DISEASE
30 pounds in one month. Cough.Bloody sputum. Very weak appetite is poor severe
watery
DISEASE
diarrhea
DISEASE
(Admission Date: [**2112-4-22**] Discharge Date: [**2112-5-5**]Date of Birth: [**2035-10-21**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 134**]Chief Complaint:
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:intubationHistory of Present Illness:76yo F with PAF s/p recent TEE-DCCV on [**4-21**]
HTN
DISEASE
admitted with
hypoxic respiratory failure
DISEASE
. She was recently hospitalized from[**Date range (1) 1919**] for a supratherapeutic INR of 16. She was in AF witha ventricular rate of 110s-140s asymptomatic. Medicalmanagement of her AF was initially tried. She was maintained onher atenolol and propafenone and diltiazem was added. Thedecision was then made to pursue cardioversion instead.TEE-DCCV was performed on [**2112-4-21**]. She was in sinus rhythmafter the procedure and had a HR in the 50s on atenolol andpropafenone upon discharge. The diltiazem had been discontinuedsecondary to
bradycardia
DISEASE
post-procedure. She was alsodischarged on Coumadin 1mg qhs. Her family states her symptomsbegan just prior to discharge when she began to feel short ofbreath and fatigued. Her symptoms progressively worsened athome. She was seen in [**Company 191**] the next morning and was found tohave O2 sats in the 80s so she was sent to the ED..In the ED her T was 100.6 HR 70s in
NSR
DISEASE
and she was 84% on4L. Her CXR showed bilateral
pleural effusions
DISEASE
and vascularengorgement and her INR was 9. She received a Combivent nebLasix 20mg IV levofloxacin 500mg IV and vitamin K 5mg SC. Shewas intubated for
hypoxia
DISEASE
. Repeat CXR showed improvement in
pulmonary edema
DISEASE
after Lasix. She was admitted to the CCU forfurther management of
hypoxia
DISEASE
due to possible
CHF
DISEASE
.Past Medical History:1.
Atrial fibrillation
DISEASE
: diagnosed [**2102**] on propafenone x severalyears started Coumadin [**4-11**] s/p TEE-DCCV on [**4-21**]2.
Hypertension
DISEASE
: on enalapril and atenololSocial History:No EtOH no past or present smoking hx no illicit drug use.Lives with her husband in [**Name (NI) 86**] has 1 daughter. Used to workin [**Country 532**] as an engineer. Moved to US from [**Country 532**] in [**2098**].Family History:Noncontributory.Physical Exam:vitals- T 98.7 HR 57 RR 13 BP 118/55 O2sat 100%vent- AC 450/14 PEEP 5 FiO2 100%General- sedated and intubatedHEENT- PERRL ETTNeck- JVP 9cmLungs- diffuse rhonchi decreased breath sounds bilaterallyHeart- RRR normal S1/S2 no murmur/rub/gallopAbd- soft NT ND NABSExt- 2Admission Date: [**2123-10-27**] Discharge Date:Date of Birth: [**2085-3-7**] Sex: MService:HISTORY OF PRESENT ILLNESS: This is a 38-year-old man with
AIDS
DISEASE
referred by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4569**] who has
fevers
DISEASE
to greaterthan 104 likely
pneumonia
DISEASE
or other pulmonary processincreasing for one month. He reports increased
cough
DISEASE
usually nonproductive but occasional production of bloodysputum. In addition he has some dark stool which he statesis maroon in color in the last few weeks as well as
nausea
DISEASE
and
vomiting
DISEASE
. He states that sometimes he
vomits
DISEASE
blood.Reports left upper quadrant
pain
DISEASE
times one month with eating.
Denies dyspnea
DISEASE
or
chest pain
DISEASE
. He states some
pain
DISEASE
in hischest with
cough
DISEASE
only and that's resolved mild
headache
DISEASE
likea hot plate on his forehead mild
neck pain
DISEASE
positive urinaryfrequency and
dysuria
DISEASE
times weeks. Today he has had
diarrhea
DISEASE
30 minutes after meals. He states he has been
depressed
DISEASE
not sleeping and wants to die without active
suicidal ideation
DISEASE
.PAST MEDICAL HISTORY:1. HIV diagnosed in [**2118**] treated with HAART in [**2122-7-2**]viral load was 50000 went to less than 50 but then patientquit his medications after his rectal abscess. Last CD4count [**2123-7-2**] was 1 viral load in [**2123-6-1**] was greaterthan 500000.2. Kaposi's of skin oral cavity and lung status postchemotherapy in [**2119**].3. ......... of the skin buttocks in [**2122-4-1**].4. History of
neutropenia
DISEASE
exacerbated by Bactrim andresolved with discontinuation.5. HSV2 resolved [**2123-6-1**] perianal.6. History of
perianal abscess
DISEASE
in [**2122**] status post surgery.7. Left upper lobe pneumonia in [**2123-7-10**] treated withlevofloxacin and resolved.8. Recurrent
zoster
DISEASE
.9.
Pancreatitis
DISEASE
.10. Oral
ulcers
DISEASE
and [**Female First Name (un) **]
esophagitis
DISEASE
.11.
Depression
DISEASE
.12.
Tinea
DISEASE
barba.SOCIAL HISTORY: 45 pack year of tobacco. Formerly 12-24beers most recently until five days ago.FAMILY HISTORY: Noncontributory.ALLERGIES: Bactrim intolerance.MEDICATIONS: Patient on only one month in [**Month (only) 205**] acyclovir 800t.i.d. times 30 days then b.i.d. azithromycin 250 timesfive q. week dapsone 100 q.d. Epivir 150 b.i.d. Indinavir400 b.i.d. Paxil 20 Prilosec 20 Ritonavir 100 times fourb.i.d. stavudine 40 b.i.d.REVIEW OF SYSTEMS: No
rigors fevers
DISEASE
and
chills
DISEASE
and
sweats
DISEASE
today only.
Weight loss
DISEASE
30 pounds in one month. Cough.Bloody sputum. Very weak appetite is poor severe
watery
DISEASE
diarrhea
DISEASE
(Admission Date: [**2123-12-31**] Discharge Date: [**2124-1-10**]Date of Birth: [**2085-3-7**] Sex: MService: MedicineADDENDUM: The patient is a 38 year old [**Country 4574**] male with
AIDS
DISEASE
left upper lobe aspergilloma and lower extremity
paraparesis
DISEASE
who was originally admitted on [**2123-10-26**] with
fever
DISEASE
and
cough
DISEASE
. He was subsequently found to havean
left upper lobe aspergilloma
DISEASE
which was initially treatedwith amphotericin which led to the patient having
seizures
DISEASE
.He was then placed in a phenobarbital coma which slowlyresolved and was started on itraconazole therapy. Pleaserefer to the dictation summary dictated on [**2124-1-5**]dictated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].1. Neurologic: On [**2123-12-29**] the patient begancomplaining of
dizziness
DISEASE
. He did not describe a roomspinning sensation. He felt like his head was falling to theside but no particular side consistently. He did notcomplain of new
numbness weakness
DISEASE
or tingling. He did notcomplain of
dysphagia dysarthria
DISEASE
hearing changes sense of
fullness
DISEASE
in the ear or
headache
DISEASE
. He had no focal deficits onexamination.The patient was started on Meclizine and initially showedimprovement on that. Approximately one week after theMeclizine was started the patient was changed to a lowerdose of Meclizine. After that change the patient beganexperiencing
dizziness
DISEASE
again. Subsequently neurology wasconsulted on hospital day number 75. Neurology felt that thepatient's
dizziness
DISEASE
was likely multi-factorial. The causewas believed to be vestibular peripheral superimposed axialand
lower extremity weakness
DISEASE
with prolonged immobility.Additionally multiple medications that the patient wastaking have been associated with
dizziness
DISEASE
including thepatient's
seizure
DISEASE
medications. Neurology recommendedchecking a phenobarbital level. On [**2124-1-9**] thelevel was 23 which was in the therapeutic range. Neurologyalso recommended considering a magnetic resonance imagingscan if the patient's
dizziness
DISEASE
did not resolve or worsened.Additionally they recommended discontinuing Reglan if thepatient's symptoms did not resolve and the Reglan was notdeemed necessary. The patient did not have any further
seizures
DISEASE
during this hospitalization.2. Infectious disease: The issue of reverse transcript ACEinhibitors was revisited within the last two weeks. The casewas discussed with
infectious disease
DISEASE
who have beenfollowing the case. At this time they recommended holdingon adding reverse transcript ACE inhibitors. The patient'samylase level on [**2124-1-7**] was 306. When the amylaselevel returns to normal the
infectious disease
DISEASE
service willrevisit the issue of reverse transcript ACE inhibitors.The patient was started on protease inhibitors on [**2123-12-26**]. According to fetal distress the patient may stayon double protease inhibitor therapy for up to three monthsbefore resistance occurs. The plan is to revisit the issueof reverse transcript ACE inhibitors once the patient'samylase level is within normal limits.On hospital day number 73 the patient developed a 1 to 2 cm
ulcer
DISEASE
at the perineum. It was mildly tender to palpation.The patient was started on acyclovir. This also was presumedto be due to
herpes simplex virus type II
DISEASE
.3. Physical therapy and occupational therapy: The patientcontinued to improve over the course of the hospitalization.On discharge the patient was able to ambulate approximately200 feet with a standard walker. The patient's lowerextremity strength was continuing to improve each day. Thepatient was also able to climb several stairs.DISPOSITION: The patient will need to follow up with the
Infectious Disease
DISEASE
Clinic in two to three weeks afterdischarge (telephone number [**Telephone/Fax (1) 457**]).DISCHARGE MEDICATIONS:Acyclovir 800 mg p.o.t.i.d.Amprenavir 450 mg p.o.b.i.d.Azithromycin 1.2 gm p.o.q. Wednesday.
Desitin
DISEASE
applied to affect area p.r.n.Colace 100 mg p.o.b.i.d.Ibuprofen 600 mg p.o.t.i.d.Itraconazole 200 mg p.o.q.d.Lansoprazole 30 mg p.o.q.d.Levetiracetam 500 mg p.o.b.i.d.Lidocaine jelly 2% applied to affected area.Meclizine 25 mg p.o.b.i.d.Metoclopramide 5 mg p.o.q.i.d.Multivitamins one p.o.q.d.Neutra-Phos one p.o.q.d.Phenobarbital 90 mg p.o.b.i.d.Ritonavir 100 mg p.o.b.i.d.Sodium chloride nasal spray b.i.d.Bactrim DS one p.o.q.d.Tobramycin one drop applied to each eye q.i.d.CONDITION AT DISCHARGE: Excellent.DISCHARGE STATUS: Good. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4570**] M.D. [**MD Number(1) 4571**]Dictated By:[**Name8 (MD) 4575**]MEDQUIST36D: [**2124-1-9**] 15:30T: [**2124-1-9**] 15:29JOB#: [**Job Number 4576**]Admission Date: [**2140-1-8**] Discharge Date: [**2140-1-14**]Date of Birth: [**2060-1-20**] Sex: FService: MEDICINE
Allergies
DISEASE
:Sulfonamides / Motrin / Erythromycin BaseAttending:[**First Name3 (LF) 898**]Chief Complaint:
dyspnea fatigue
DISEASE
Major Surgical or Invasive Procedure:central line placementHistory of Present Illness:78 F with h/o
asthma
DISEASE
seen at [**Hospital1 18**] ED on [**1-7**] and found to haveLLL pneumonia. Pt was sent home on antibiotics and asked toreturn on [**1-8**] were she was found to be increasingly dyspneictachycardic 120's and hypoxic 50% (
RA
DISEASE
). Pt was immediatelyintubated in the ED and found to have ABG of 71.5/69/556 afterintubation. Pt was transfered to the ICU for
hypercarbic
DISEASE
respitory
failure
DISEASE
on [**1-8**].Past Medical History:1.
asthma
DISEASE
2.
cataracts
DISEASE
3. severe bilateral
hearing loss
DISEASE
4.
allergic rhinitis
DISEASE
Social History:Lives alone in [**Location (un) **] MA. She is a widow. She has onedaughter that lives in [**Location 652**] CA. Her phone #[**Telephone/Fax (1) 4577**]. She does not smoke or drink EtOH.Family History:no
cancer
DISEASE
or
diabetes
DISEASE
Physical Exam:T 98.9 BP 121/60 HR 120 RR 16A/C 400x18 PEEP 8 FI02 50%Gen: intubated sedatedHEENT: PERRLNeck: supple no LADLungs: diffuse b/l wheezingAdmission Date: [**2159-9-10**] Discharge Date: [**2159-9-25**]Service:ORTHOHISTORY OF PRESENT ILLNESS: This is an 82 year-old womanwith a history of
hypertension
DISEASE
status post cerebrovascularaccident with residual left sided weakness status post rightCEA in [**2155**] who is admitted for an L4-S1 decompression/fusionon [**9-10**]. The patient's postoperative course waselectrocardiogram with new T wave inversions laterally butotherwise not significantly changed. The patient ruled outby enzymes after this incident and was transferred to thefloor. The patient also received intraoperative Labetalolfor
hypertension
DISEASE
. Telemetry overnight after her episode of
chest pain
DISEASE
demonstrated
premature ventricular contractions
DISEASE
and
bigeminy
DISEASE
. The patient was seen by cardiology consultpressure control. On [**9-14**] the patient began todevelop paroxysmal
atrial fibrillation
DISEASE
with a rapidventricular response and was subsequently anticoagulated onheparin and Coumadin and placed on Amiodarone. However on[**9-18**] the patient's hematocrit dropped from 36 to 24with a decrease in blood pressure and was found to have arectus sheath
hematoma
DISEASE
. The patient received 6 units ofpacked red blood cells 5 units of fresh frozen platelets andher anticoagulation reversed. The patient was transferred tothe SICU where arterial line was placed and the patient wasplaced on Nipride.On [**9-21**] the patient was stable and transferred to thefloor with a resorbing
hematoma
DISEASE
and a normal sinus rhythm.She at that point was denying
chest pain shortness
DISEASE
of
breath lightheadedness
DISEASE
although she was having some
abdominal tenderness
DISEASE
. She was noted to have been having sometrouble with po and is being followed by the speech andswallow team and was also noted to have some
confusion
DISEASE
andmental status changes.PAST MEDICAL HISTORY: 1. Hypertension. 2. Small vesselcerebrovascular accident in [**2153-3-26**] with residual leftsided weakness. 3. Bilateral
carotid stenosis
DISEASE
status postright CEA in [**2155**] and with left CVBD. In [**2159-5-27**] thepatient was noted to have mild
right ICA plaque
DISEASE
and 60 to 69%[**Doctor First Name 3098**]. 4. Status post spinal fusion [**2159-9-10**]. 5.Status post echocardiogram in [**2150**] demonstrating normal leftventricular function and trace AI. Status post ETT in [**2150**]with equivocal results. 6. Status post parotid glandexcision at [**Hospital1 2025**] for a
tumor
DISEASE
.MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg po q day. 2.Detrol 1 mg po b.i.d. 3. Cozaar 25 mg po t.i.d. 4. MVI 1po q.d. 5. Zoloft 25 mg po q.d.ALLERGIES: The patient is Admission Date: [**2149-11-15**] Discharge Date: [**2149-12-5**]Date of Birth: [**2080-11-2**] Sex: MService:HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 68 year old gentlemanwith a history of
coronary artery disease
DISEASE
previous coronaryartery bypass graft with severe known
aortic stenosis
DISEASE
who hadbeen scheduled for an aortic valve replacement on [**2149-11-17**] with Dr. [**Last Name (Prefixes) **]. The patient presented to theEmergency Department on [**2149-11-15**] with increasing
shortness of breath
DISEASE
. The patient had previously beenadmitted to Dr. [**Last Name (Prefixes) **] for apical aortic conization.The procedure was aborted in the Operating Room due toevidence of a significant amount of
aortic insufficiency
DISEASE
.The patient was subsequently discharged to home and scheduledfor [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**] M.D. [**MD Number(1) 414**]Dictated By:[**Last Name (NamePattern1) 3870**]MEDQUIST36D: [**2149-12-4**] 17:02T: [**2149-12-4**] 21:37JOB#: [**Job Number 3871**]Admission Date: [**2149-11-15**] Discharge Date: [**2149-12-5**]Date of Birth: [**2080-11-2**] Sex: MService: CA/TH [**Doctor First Name 147**]HISTORY OF PRESENT ILLNESS: This is a 69 -year-old malepatient who was admitted to [**Hospital3 **] - [**Hospital **] [**First Name (Titles) **][**Last Name (Titles) **] through the Emergency Department on [**2149-11-15**]with increasing
shortness of breath
DISEASE
. The patient had aprevious hospitalization from [**11-2**] through [**11-6**]for which he was scheduled for an attempted apicalcanalization. However he was found to have significant
aortic insufficiency
DISEASE
and the procedure was aborted.Th[**Last Name (STitle) 1050**] was discharged home on [**2149-11-6**] withoutdiuretic and he was scheduled to undergo aortic valvereplacement on [**11-17**] with Dr. [**Last Name (Prefixes) **]. Onadmission to the hospital the patient was noted to have achest x-ray which was significant for a right pleuraleffusion as well as
congestive heart failure
DISEASE
.PAST MEDICAL HISTORY:1. Coronary
artery disease
DISEASE
status post coronary arterybypass graft times five in [**2140**].2. Status post
myocardial infarction
DISEASE
in [**2129**].3. Aortic stenosis with
aortic insufficiency
DISEASE
with acalculated aortic valve area of 0.8-0.9.4. Asthma.5. ETOH abuse. The patient states that last drink was on[**2149-11-15**]. The patient admits to smoking one pack adayAdmission Date: [**2149-11-15**] Discharge Date: [**2149-12-5**]Date of Birth: [**2080-11-2**] Sex: MService:HISTORY OF PRESENT ILLNESS: This is a 69 year old malepatient who was admitted to [**Hospital1 188**] through the Emergency Department on [**2149-11-15**]with increasing
shortness of breath
DISEASE
. The patient had aprevious hospitalization from [**11-2**] through [**11-6**] for which he was scheduled for an attempted apicalconization however he was found to have significant aortic
insufficiency
DISEASE
and the procedure was aborted. The patient wasdischarged home on [**2149-11-6**] without diuretic and hewas scheduled to undergo aortic valve replacement on [**11-17**] with Dr. [**Name (STitle) 3876**].On admission to the hospital the patient was noted to have achest x-ray which was significant for a right pleuraleffusion as well as
congestive heart failure
DISEASE
.PAST MEDICAL HISTORY:1. Coronary
artery disease
DISEASE
status post coronary artery bypass graft times five in [**2140**].2. Status post
myocardial infarction
DISEASE
in [**2129**].3. Aortic stenosis with
aortic insufficiency
DISEASE
with a calculated aortic valve area of 0.8 to 0.9.4. Asthma.5. ETOH abuseAdmission Date: [**2155-4-8**] Discharge Date: [**2155-4-9**]Service: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 3565**]Chief Complaint:Chief Complaint: lymphoma work-up.Reason for MICU transfer: airway monitoringMajor Surgical or Invasive Procedure:None this hospitalizationHistory of Present Illness:Patient is a [**Age over 90 **] yo F with hx nasal congestion and
serous otitis
DISEASE
media found to have nasopharyngeal mass now POD #6 s/p nasalendoscopy w/ biopsy bilateral tube placement. Mass biopsyreturned w/ diagnosis of
aggressive lymphoma
DISEASE
involving nasalcavity and possible airway compromise. She was started on abx 4days ago for
bronchitis
DISEASE
. She was sent by Dr. [**Last Name (STitle) 3877**] for ENTeval due to concern for airway involvement given extent of
tumor
DISEASE
. Pt denies
fevers chills
DISEASE
n/v
chest pain shortness
DISEASE
ofbreath. She does endorse
pain
DISEASE
in her left cheek..In the ED initial VS were 98.5 72 152/116 16 99%
RA
DISEASE
. Her labswere notable for normal K Phos Ca uric acid but elevated LDH.She was seen by ENT who did not recommend surgical intervention.She had CT od head/ neck/ torso for staging. She receiveddexamethasone 20 mg IV x 1 as well as allopurinol 300 mg podaily. She was admited to [**Hospital Unit Name 153**] for airway monitoring. Her vitalsigns prior to transfer were: 134/82 65 22 97%
RA
DISEASE
..On arrival to the ICU patient is comfortable with only mildleft sided facial
pain
DISEASE
requesting to be discharged in themorning.Past Medical History:Past Medical History:NP mass- s/p biopsy showing lymphoma
HTN
DISEASE
hypothyroidism
DISEASE
Social History:Lives alone. daughter visits once a week to help with shoppinghousehold chores. she denies tobacco alcohol illicits.Family History:
Denies cancer
DISEASE
in the family.Physical Exam:ADMISSION
EXAM
DISEASE
:.General: Alert oriented no acute distressHEENT: scleric anicteric MMM
fullness
DISEASE
over left cheek and neckNeck: supple JVP not elevated no LADLungs: Clear to auscultation bilaterally no
wheezes rales
DISEASE
rhonchiCV: Regular rate and rhythm normal S1 Admission Date: [**2142-12-27**] Discharge Date: [**2143-1-1**]Date of Birth: [**2086-7-17**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 922**]Chief Complaint:
dyspnea
DISEASE
on exertionMajor Surgical or Invasive Procedure:[**12-27**] MVR (25/33 ON-X mechanical valve)History of Present Illness:55 yo M with long history of myxomatous MV and chronic MR.Serial echos showed increased LA/LV dimensions and and severe
MR
DISEASE
and normal EF.
Referred
DISEASE
for surgery.Past Medical History:MR/MVP Migraines Ankylosing
spondylitis GI bleed
DISEASE
(10 yearsago)
Hyperlipidemia HTN B hernia
DISEASE
repairSocial History:works as architectquit tobacco 27 years agono etohFamily History:mother with MVR Admission Date: [**2176-3-19**] Discharge Date: [**2176-3-25**]Date of Birth: [**2098-7-3**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:DemerolAttending:[**First Name3 (LF) 922**]Chief Complaint:
Exertional dyspnea
DISEASE
Major Surgical or Invasive Procedure:[**2176-3-19**]1. Aortic valve replacement with a 27-mm [**Company 1543**] Ultra Aortic Valve Bioprosthesis.2. Epiaortic duplex scanning.History of Present Illness:Mr. [**Known lastname **] is a 77yo male with known
aortic stenosis
DISEASE
and
coronary artery disease
DISEASE
. He has been followed with serialechocardiograms which have shown progression of his aortic valvedisease. Over the last year to six months hehas developed slight
exertional dyspnea
DISEASE
most notable on his onemile walk which he does routinely as well as taking out thetrash barrels subtle but a change. Dr [**Last Name (STitle) 914**] was consulted forsurgical evaluationPast Medical History:Past Medical History- Aortic Stenosis- Coronary Artery Disease-
Dyslipidemia
DISEASE
-
Hypertension
DISEASE
- Prior CVA affecting left eye ( 10 yrs ago)- Carotid Disease Right ICA- L subclavian steal- Left Renal Artery Stent- Chronic Renal Insufficiency baseline Cr around 2.0-
Rheumatoid Arthritis
DISEASE
- Macular Degeneration ( legally blind)-
Cognitive Impairment
DISEASE
progressive
memory loss
DISEASE
- History of
Mesenteric artery insufficiency
DISEASE
-
Cataracts
DISEASE
-
Anemia
DISEASE
Past Surgical History:-tonsillectomy-R
cataract
DISEASE
[**Doctor First Name **]Social History:-Tobacco history: quit 45 yrs ago used to smoke 1PPD x 25 yrs-ETOH: drinks 4-6 beers on wknd-Illicit drugs: deniesFamily History:Pt reports that his father had
heart problems
DISEASE
but unsure whatkind as died when pt was 9 at age 60. [**Name (NI) 1094**] sister had a valvereplaced at age 81 but died at age 82 from
colon cancer
DISEASE
. [**Name (NI) 1094**]brother also had rhematic
fever
DISEASE
when he was a child but died of
alcoholism
DISEASE
related causes.Physical Exam:AdmissionPulse: 60 Resp:16 O2 sat: 98%B/P Right:124/54 Left: 96/55Height: 67Admission Date: [**2157-2-1**] Discharge Date: [**2157-2-8**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1928**]Chief Complaint:
Abdominal pain
DISEASE
Major Surgical or Invasive Procedure:ERCP with sphincterotomy and biliary stent placement on [**2157-2-1**]History of Present Illness:Mrs. [**Known firstname 1929**] [**Known lastname 1930**] is a very nice 85 year-old woman with ahistory of cholecystectomy and
ampullar stenosis
DISEASE
who presentswith
RUQ abdominal pain
DISEASE
. She states her
pain
DISEASE
started 2 daysprior to admission was constant and radiated towards the back.She had
nausea vomit malaise
DISEASE
. Denies fever chills changesin her
bowel movements hematochezia
DISEASE
or
melena
DISEASE
. Unable able totolerate oral intake.Presenting vitals were T 101.5 HR 68 BP 152/76 RR 16 SpO295%
RA
DISEASE
. In ED Unasyn 3gm given and a right IJ central line wasplaced. She underwent ERCP that showed 1-cm stone in the commonbile duct. Patient became hypoxic from the conscious sedationso the stone was not removed to expedite the procedure. Aplastic biliary stent was successfully placed. Post-ERCP shewas admitted to the ICU with a diagnosis of
cholangitis
DISEASE
.ICU course: In the ICU the patient was continued on Zosyn her
RUQ pain
DISEASE
significantly improved and she began to toleratefluids. On [**2-3**] she developed
shortness of breath
DISEASE
thatimproved with administration of furosemide. Nebulizertreatments also given. At time of transfer to floor O2 sat was95% on 2L nasal canula. Lisinopril restarted but Atenolol andNifedipine held for concern of lower heart rate.She was transferred to the floor and felt improvement in her
abdominal pain
DISEASE
. Denied
shortness of breath chest pain
DISEASE
.Past Medical History:1.
Hypertension
DISEASE
2. Ampullary stenosis3. Status post cholecystectomy for
gallstones
DISEASE
4. History of sphincterotomy (as described above)5.
Osteoporosis
DISEASE
6.
Gastroesophageal reflux disease
DISEASE
7.
External hemorrhoids
DISEASE
8.
Cerebrovascular accident
DISEASE
in [**2145**] (right pontine)9.
Parkinson's
DISEASE
diseae10. Chronic low back
pain
DISEASE
with
sciatica
DISEASE
11. Urinary frequency and urge
incontinence
DISEASE
12. Diverticulosis13. Chronic
pancreatitis
DISEASE
Social History:She lives by herself. She came the US in [**2138**] from [**Country 1931**] andis Russian-speaking. Denies alcohol tobacco and no drugs.Family History:No family of MI
stroke
DISEASE
son
prostate cancer
DISEASE
. Daughter with[**Name2 (NI) 1932**].Physical Exam:Admission Exam:VS: Temp 97.8 F BP 108/30 mmHg HR 78 BPM RR 14 O2-sat 93%
RA
DISEASE
GEN: Well-appearing woman in NAD comfortable
jaundiced
DISEASE
(skinmouth conjuntiva)HEENT: NC/AT PERRLA EOMI
sclerae icteric
DISEASE
MMM OP clearNECK: Supple no thyromegaly no JVD no
carotid bruits
DISEASE
LUNGS: CTA bilat no r/rh/wh good air movement resp unlaboredno accessory muscle useHEART: PMI non-displaced RRR no MRG nl S1-S2ABDOMEN: NABS soft/NT/ND no masses or HSM norebound/guarding.EXTREMITIES: WWP no c/c/e 2Admission Date: [**2138-9-2**] Discharge Date: [**2138-9-7**]Date of Birth: [**2073-1-19**] Sex: MService: NEUROSURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1271**]Chief Complaint:CC:[**CC Contact Info 3898**]Major Surgical or Invasive Procedure:s/p anterior cervical discectomy C2-C3History of Present Illness:HPI: 65M was outdoors cutting tree branch when 700# branch hithim on the head. He was found upside down in his harness withthebranch on the ground. Found to have L
occipital laceration
DISEASE
thatwas stapled at OSH.
GCS
DISEASE
15. Transferred to [**Hospital1 18**] for furtherevaluation.Past Medical History:htnSocial History:lives aloneex wife lives on [**Location (un) 945**]Family History:unknownPhysical Exam:On arrivalPHYSICAL
EXAM
DISEASE
:afeb 68 145/70 22 96%Gen: WD/WN comfortable NAD.HEENT: Pupils: R 2.5-Admission Date: [**2179-11-2**] Discharge Date: [**2179-11-5**]Date of Birth: [**2123-11-14**] Sex: FService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 633**]Chief Complaint:
diabetic ketoacidosis
DISEASE
Major Surgical or Invasive Procedure:central line placement in EDHistory of Present Illness:Pt is a 55 yo F with no significant PMH who presented to PCP[**Name Initial (PRE) 151**] 3 days of profound
fatigue
DISEASE
and DOE. Pt states she Admission Date: [**2100-12-21**] Discharge Date: [**2100-12-23**]Date of Birth: [**2034-6-22**] Sex: FService: MEDICINE
Allergies
DISEASE
:BactrimAttending:[**Doctor First Name 1402**]Chief Complaint:post ablation complicationMajor Surgical or Invasive Procedure:
Pulmonary Vein
DISEASE
Isolation unsuccessfulPericardial DrainHistory of Present Illness:Ms. [**Known lastname 3912**] is a 66 y/o F with a history of pAtrial
Fibrillation
DISEASE
(not controlled on Flecanide/DigoxinAdmission Date: [**2103-9-27**] Discharge Date: [**2103-10-30**]Date of Birth: [**2058-7-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:Bleomycin / BactrimAttending:[**First Name3 (LF) 3913**]Chief Complaint:
Fever
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:45 yo M with a long history of recurrent
Hodgkin's lymphoma
DISEASE
s/pauto and allogeneic transplant with recurrence on monthlychemotherapy admitted after he presented for scheduledchemotherapy with
fevers
DISEASE
to 101 in clinic and transferred to theICU for persistent
hypotension
DISEASE
after bronchoscopy..The patient initially presented to clinic on [**2103-9-27**] forscheduled Gemzar navelbine and decadron therapy. He was foundto have a
fever
DISEASE
to 101. On review of systems at that time thepatient did admit to feeling fatigued and generally unwellpossibly with a component of pleuritic
chest pain
DISEASE
and
dry cough
DISEASE
.CXR at that time revealed an evolving RLL and lingular/LULinfiltrate. He was admitted for further evaluation with CXR andCT chest concerning for evolving
pneumonia
DISEASE
. The patient wasstarted on Vancomycin Cefepime and Voriconazole. During hishospital stay the patient did have relative
hypotension
DISEASE
as atbaseline to the range of sbp 90's with
tachycardia
DISEASE
to the low100's. The patient did have individual sbp measurementsovernight prior to transfer as low as 80's reportedly fluidresponsive..The patient was brought to the ICU for elective bronchoscopy.During the procedure the patient received 1mg midazolam and abolus of 25mcg of fentanyl. Post-procedure the patient waspersistently
hypotensive
DISEASE
to the range of sbp 78-82 with intactmentation though some complaints of feeling tired and mildlylightheaded. His
hypotension
DISEASE
was refractory to 1L of NS. Thepatient was kept in the [**Hospital Unit Name 153**] for further monitoring..Of note the patient has a history of multiple episodes of
pneumonia
DISEASE
in the past most recently with
fungal pnuemonia
DISEASE
basedupon positive galactomannan in [**1-6**]..ROS: Denies any recent sick contacts. Notes mild pleuritic chest
pain
DISEASE
and
nausea
DISEASE
. No
emesis abdominal pain diarrhea
DISEASE
brbpr
urinary complaints
DISEASE
.Past Medical History:Past medical/surgical history:
Hodgkin's disease
DISEASE
(see below)
Hypothyroidism
DISEASE
Asthmas/p biliary stent (see below)
Hepatitis B
DISEASE
coreAdmission Date: [**2103-11-2**] Discharge Date: [**2103-11-21**]Date of Birth: [**2058-7-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:Bleomycin / Bactrim / IV Dye Iodine ContainingAttending:[**First Name3 (LF) 3913**]Chief Complaint:
Respiratory distress
DISEASE
Major Surgical or Invasive Procedure:Mechanical ventilation ([**Date range (1) 3927**]/08)History of Present Illness:45 yo M with PMH of recurrent
Hodgkin's lymphoma
DISEASE
(since [**2094**])s/p auto and allogeneic transplant with recurrence lastchemotherapy (gemcitabine navelbine decadron [**2103-8-30**]) Admission Date: [**2104-2-28**] Discharge Date: [**2104-3-7**]Service: MEDICINE
Allergies
DISEASE
:Xanax / AtivanAttending:[**First Name3 (LF) 134**]Chief Complaint:
Tachycardia
DISEASE
feeling unwellMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:[**Age over 90 **] M with pacemaker admitted for rapid afib. In [**2102**] he had adual chamber St. [**Male First Name (un) 1525**] pacemaker placed for symptomatic
bradycardia
DISEASE
and chronitropic incompetence and has been doingfairly well. He walks his dog 1.5 miles daily. This morning hewoke up feeling lousy and tried to walk the dog but could onlymake it down the block and had to turn back. Did not have enoughenergy and felt some lightheadedness. No
chest pain
DISEASE
or shortnessof breath. He called [**Hospital **] clinic who interogatted the pacer overthe phone and found him tachycardic. He was told to go to theED.Otherwise he feels well. On review of systems denies
fevers
DISEASE
chills nausea vomit
DISEASE
abd
pain diarrhea
DISEASE
. On cardiac review ofsystems denies orthopnea PND or increase in
peripheral edema
DISEASE
.In the ED vitals were: 98.6 128 144/85 24 100%RA. Becauseof his fast heart rates he was given dilt 10 IV x 3 and dilt 30mg PO followed by 60 mg PO.Past Medical History:#
Chronic renal failure
DISEASE
- Followed by Dr. [**Last Name (STitle) **]. On Epogen.- Baseline creatinine is 2.0 - 2.4.#
Claudication
DISEASE
- Walks 1.5 miles daily but has to stop and rest.#
Aortic stenosis
DISEASE
- Mean gradient 60 on last ECHO [**9-6**]- Declined AVR or valvuloplasty#
B12 deficiency
DISEASE
#
HTN
DISEASE
# GERD# PVD# H/O
stomach cancer
DISEASE
- s/p total gastrectomy and Roux-en-Y in late [**2085**]#
Left renal artery stenosis
DISEASE
- s/p stenting [**2102-3-8**]# Type 2 DM#
Hyperkalemia
DISEASE
in the past attributed to dietary supplements# Paroxysmal atrial fib- reported after gastrectomy but no h/o recurrence#
COPD
DISEASE
#
TIA
DISEASE
#
Abdominal aortic aneurysm
DISEASE
repair# Right ICA 50% occluded [**Doctor First Name 3098**] 90% occludedSocial History:Lives at home with his wife. [**Name (NI) **] [**Name (NI) **] [**Known lastname 3937**] is a ED physicianin [**Name9 (PRE) 1727**]. Phone numbers are [**Telephone/Fax (1) 3938**] and [**Telephone/Fax (1) 3939**].Patient is a retired jazz musician--- played the clarinet andsax. No ETOH or drugs. Smoked [**3-4**] PPD for 30 years but quitapproximately 20 years ago.Family History:No fam hx or early CAD.Physical Exam:VITALS: 97.1 143/62 76 20 100%2LNCGEN: AAdmission Date: [**2104-10-28**] Discharge Date: [**2104-10-31**]Service: CARDIOTHORACIC
Allergies
DISEASE
:Xanax / AtivanAttending:[**First Name3 (LF) 3948**]Chief Complaint:
Hemoptysis
DISEASE
Major Surgical or Invasive Procedure:Intubation and mechanical ventilationFlexible bronchoscopy with therapeutic aspirationHistory of Present Illness:[**Age over 90 **] yo man with
aortic stenosis CRF left renal artery stenosis
DISEASE
COPD
DISEASE
tobacco abuse who called EMS for acute dyspnea/hemoptysislast night. Had approx 5 tbl of BRB followed by a few episodesof coin sized blood.Per patient's wife patient was lethargic and sleepy after d/clast week from hospital. [**Name (NI) **] wife awoke around 230amtoday when patient was
coughing up blood and
DISEASE
noted to bedyspneic. She also states that the VNA noted some Admission Date: [**2135-6-15**] Discharge Date: [**2135-7-22**]
Service: Vascular SurgeryCHIEF COMPLAINT: Ruptured infected right femoral
pseudoaneurysm
DISEASE
.HISTORY OF PRESENT ILLNESS: This 82 year old white femalewith
coronary artery disease coronary artery bypass graft
cerebrovascular accident diabetes hypertension renal
artery stenosis
DISEASE
status post left renal artery stent
peripheral vascular disease
DISEASE
had undergone a right commonfemoral to anterior tibial artery bypass graft with PTFE on[**2132-11-27**] by Dr. [**Last Name (STitle) **]. After the patient developed
gangrene
DISEASE
of her lower saphenectomy site with two
ulcers
DISEASE
.The patient did well until she had a catheterization via herright groin in [**2135-4-28**]. The patientdeveloped a right groin
hematoma
DISEASE
which was evacuated in [**2135-4-28**]. At that time there was no graft involvement.The patient was sent to the [**Hospital6 2018**] Emergency Room from [**Hospital6 310**] on[**2135-6-15**] with recent history of
fevers
DISEASE
and developmentof a pulsatile mass in her right groin. The right groinbegan to
bleed
DISEASE
and the patient was sent for evaluation. Inthe Emergency Room the patient was diagnosed with an infected
pseudoaneurysm
DISEASE
and was admitted for emergency surgery.PAST MEDICAL HISTORY:1. Coronary artery disease: NWQMI percutaneoustransluminal coronary angioplasty/stent [**2132-6-23**]coronary artery bypass graft [**2132-8-24**].2. Cerebrovascular accident [**2128**] no residual.3. Right medullary cerebrovascular accident [**2135-3-29**].4. Seizure disorder hospitalized [**2129-4-28**] at [**Hospital6 1760**].5. Diabetes diagnosed in [**2123**].6.
Hypertension
DISEASE
.7.
Hypercholesterolemia
DISEASE
.8. Carotid
artery stenosis
DISEASE
.9. Renal artery stenosis stent placement left renal artery[**2135-3-29**].10. Recurrent
urinary tract infection
DISEASE
.11. Severe
depression
DISEASE
status post electroconvulsive therapy[**2123**] and [**2125**].12. Left femoral neck fracture.13.
Right groin hematoma
DISEASE
.14. Recurrent
urinary tract infections
DISEASE
.15.
Peripheral vascular disease
DISEASE
.PAST SURGICAL HISTORY:1. Coronary artery bypass graft times three with right legsaphenous vein on [**2132-8-24**] by Dr. [**Last Name (STitle) **] at [**Hospital6 1760**].2. Right common femoral to anterior tibial artery bypassgraft with PTFE and distal tailor vein patch on [**2132-11-27**] by Dr. [**Last Name (STitle) **].3. Left closed reduction internal fixation of left hip
fracture
DISEASE
and evacuation of right groin
hematoma
DISEASE
on [**2135-5-2**] at [**Hospital6 256**].ALLERGIES: No known
drug allergies
DISEASE
.ADMISSION MEDICATIONS:1. Aggrenox2. Aspirin3. Lisinopril4. Amlodipine5. Atorvastatin6. Lopressor7. Bupropion8. Mirtazapine9. Temazepam10. Trazodone11. Dulcolax12. Tylenol13. Sublingual Nitroglycerin14. RISS15. VancomycinFAMILY HISTORY: Non-contributory.SOCIAL HISTORY: The patient was at [**Hospital6 3953**] prior to admission. She does not drink alcohol. Shedoes not smoke cigarettes. She has a son daughter-in-lawand daughter who are very involved in her care.ADMISSION LABORATORY DATA: White blood count 9.4 hemoglobin7.8 hematocrit 22.5 platelets 314000 PT 13.9 PTT 28.8INR 1.3. Sodium 143 potassium 4.5 chloride 108bicarbonate 26 BUN 54 creatinine 1.1 glucose 124.HOSPITAL COURSE: The patient was evaluated in the EmergencyRoom. She was noted to have a
bleeding
DISEASE
pulsatile mass in herright groin. She had a
fever
DISEASE
to 102. She was taken to theOperating Room for emergent repair of her infected rightgroin
pseudoaneurysm
DISEASE
. The proximal prosthetic graft wasremoved. The distal prosthetic graft could not be separatedfrom the surrounding tissue and therefore was ligated. Aright common femoral to profunda femoris artery bypass graftwith right superficial femoral artery was done. The patientreceived 6units of packed red blood cells intraoperatively for herhematocrit of 22. Post transfusion hematocrit was 33.7.The patient was kept on heparin infusion. She was started onVancomycin Levofloxacin and Flagyl. At the end of surgerythe patient had a cool right lower extremity from the foot tothe knee. No doppler signals were found at the dorsalis
pedis
DISEASE
or posterior tibial. Dr. [**Last Name (STitle) **] felt there was nopossibility of revascularization. He discussed the necessityof an above the knee amputation in the future with thefamily. Postoperatively the patient remained intubated. Herurine output decreased considerably. She was determined tobe in
metabolic acidosis
DISEASE
. Tube feedings were started viaoral gastric tube. Blood cultures grew
Methicillin-resistant
DISEASE
Staphylococcus aureus. Tissue culture grew
Methicillin-resistant Staphylococcus
DISEASE
aureus.The Renal Service was consulted for the patient's
oliguria
DISEASE
and elevated creatinine from 1.5 to 2.2. Because of her
renal artery stenosis
DISEASE
and recent
left renal artery
DISEASE
stentplacement they felt the patient's right kidney was notfunctioning. They therefore recommended that her systolicblood pressure be kept greater than 140 and less than 180 tomaintain adequate renal perfusion. In the meantime untilrenal function improved all medications were to be dosed fora creatinine clearance of approximately 25 cc/hr.The patient failed multiple attempts to wean her toextubation. She was felt to be fluid overloaded as well ashaving extremely thick secretions. She was diuresed withLasix prn and then a Lasix drip. She had a bronchoscopy on[**2135-6-27**] and secretions grew
Methicillin-resistant
DISEASE
Staphylococcus aureus. Chest x-ray showed a left lungcollapse and she had a repeat bronchoscopy on [**2135-7-1**].Secretions again grew
Methicillin-resistant Staphylococcus
DISEASE
aureus. On [**2135-7-2**] large
pleural effusion
DISEASE
was seen andthe patient underwent ultrasound-guided aspiration of theleft
pleural effusion
DISEASE
. One liter of fluid was drained.Cultures were negative. Possibility of a tracheotomy wasdiscussed with the family who refused to consider it at thattime. Following the pleural tap the patient continued toimprove and was finally extubated [**2135-7-6**].Postoperatively she did fairly well with Albuterol andIpratropium inhalation as well as Albuterol and Ipratropiumnebulizer treatment as needed. Aggressive chest physicaltherapy was also used to help clear her secretion.After extubation the patient continued to receive totalparenteral nutrition. Bedside speech and swallow evaluationcould not be done. The patient refused all food and refusedto take part in the swallow evaluation. The patient's familywas able to bring in homemade foods which the patient wasable to eat small quantities. A repeat bedside evaluationdone on [**2135-7-12**] showed definite aspiration. Aspirationprecautions were put in place. The patient's familyconsented to place a percutaneous endoscopic gastrostomy.The patient was then NPO except for medications.The patient's right leg deteriorated significantly. Familydiscussed right above the knee amputation and percutaneousendoscopic gastrostomy placement with the patient on [**2135-7-15**]. A decision was made to go ahead with both procedureson [**2135-7-18**]. The patient and family requestedDo-Not-Resuscitate/Do-Not-Intubate status.The patient had developed some redness along her right groinwound with minimal drainage. Levofloxacin and Flagyl wereadded to her Vancomycin. Her abdominal staples had beenremoved on [**2135-7-1**].The patient had urine culture which grew 10000 to 100000yeast. This was treated with three days of intravenousFluconazole. A stool culture from [**2135-7-8**] was sent andwas
Clostridium difficile
DISEASE
positive. The patient was startedon a two week course of Flagyl on [**2135-7-11**].At the time of dictation the patient's right groin wound isalmost healed. She will have dry sterile dressing changesb.i.d. Her abdominal incision is clean
dry
DISEASE
and intact. Herright above the knee amputation incision is clean
dry
DISEASE
andintact. Staples should remain for one month from surgerybefore removal. Appointment with Dr. [**Last Name (STitle) **] in the officeshould be made for removal. The patient should continue herVancomycin through [**2135-7-27**]. She has been dosed perlevel less than 15. At the time of dictation she has arandom Vancomycin level pending and should receive 1 gm ofintravenous Vancomycin today. The patient will finish herFlagyl on [**2135-7-25**] for her
Clostridium difficile
DISEASE
treatment.MEDICATIONS ON DISCHARGE:1. Vancomycin through [**2135-7-27**] for
Methicillin-resistant Staphylococcus
DISEASE
aureusAdmission Date: [**2137-1-18**] Discharge Date: [**2137-2-4**]Service: VSUHISTORY OF PRESENT ILLNESS: Patient is an 83-year-oldRussian only speaking female admitted due to likely
cellulitis
DISEASE
of her right above the knee amputation stump. Herhistory was limited by absence of a family member ortranslator at the time of interview and the remainder of herhistory was obtained from her medical record.Past medical history includes
coronary artery disease
DISEASE
statuspost percutaneous transluminal coronary angioplasty and stentin [**2131**] coronary artery bypass graft in [**2132-7-29**]
cerebrovascular accident
DISEASE
in [**2128**] right medullary
cardiovascular accident
DISEASE
in [**2135-3-29**]
seizure disorder
DISEASE
diabetes hypertension hypercholesterolemia
DISEASE
carotid artery
stenosis renal artery stenosis
DISEASE
status post stent placementin the
left renal artery recurrent urinary tract infection
DISEASE
severe
depression
DISEASE
status post ECT therapy left femoral neck
fracture
DISEASE
right groin
hematoma
DISEASE
recurrent urinary tract
infections
DISEASE
peripheral vascular disease
DISEASE
.Past surgical history includes repair of a
ruptured infected
DISEASE
right femoral pseudo
aneurysm
DISEASE
coronary artery bypass graftright common femoral to anterior tibial artery bypass graftwith a PTFE and distal talar vein patch in [**2131**] by Dr.[**Last Name (STitle) **] left closed reduction internal fixation of the lefthip
fracture
DISEASE
and evacuation of right groin
hematoma
DISEASE
.SOCIAL HISTORY: Patient does not drink alcohol. She doesnot smoke cigarettes. She has a son and daughter-in-law anddaughter who are involved in her care.PHYSICAL EXAMINATION: Temperature 98.8 heart rate 70 bloodpressure 118/74 sating 96 percent on room air. In generalthe patient was alert in no acute distress. She has slightscleral
icterus
DISEASE
and some
sublingual icterus
DISEASE
. Heart isregular rate and rhythm. Lungs are clear to auscultationbilaterally. Abdomen is soft nontender obeseAdmission Date: [**2120-9-20**] Discharge Date: [**2120-9-30**]Date of Birth: [**2075-5-1**] Sex: FService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 3958**]Chief Complaint:PresyncopeMajor Surgical or Invasive Procedure:Pericardial windowHistory of Present Illness:This is a 45 y/o female with past medical history of
hypothyroidism
DISEASE
presenting initially for an urgent care visitwith an episode of diaphoresis and
presyncope
DISEASE
several hoursprior. The patient has had Admission Date: [**2182-10-17**] Discharge Date: [**2182-11-3**]Date of Birth: [**2104-4-10**] Sex: FService: MEDICINE
Allergies
DISEASE
:Penicillins / MilkAttending:[**First Name3 (LF) 1253**]Chief Complaint:s/p ERCP with acute mental status changes/aspiration PNAMajor Surgical or Invasive Procedure:ERCP with sphincteroplastyPEG tube placement (via Interventional Radiology)History of Present Illness:77 y/o F with PMhx of Developmental
Delay COPD HL HTN
DISEASE
and
Mirizzi syndrome
DISEASE
who presented today for elective ERCP. Pt wasfelt to be functionning at baseline prior to procedure with mild
agitation
DISEASE
pulling at PIVs but interacting with staff. She wasgiven fent/midaz for ERCP with stent placement and wastransferred to the post-ERCP suite in stable condition. She hadelevated BPs during the procedure requiring labetalol andmetoprolol. She was found mildly tachypneic/wheezing with
emesis
DISEASE
on her gown. It was felt likely that she had an aspiration eventwith low grade temp However she was still moving all fourextremities and responding appropriately to questions thoughmildly sedated prior to transfer to the floor..On arrival to the floor pt was minimally responsive to sternalrub and did not withdraw to focal stimuli. She was notablytachypneic and eyes were deviated to right side. She was ableto track to left with stimuli and would intermittently open eyesto command. Pt had an ABG 7.4/36/92 with lactate of 3.5 andCXR showed a right lower lobe infiltrate. Due to concern foracute
intracranial hemmorrhage
DISEASE
she was taken down for a stat CThead. On return to the floor pt was given narcan without anysignificant change in mental status. Neuro was consulted forpossible
acute stroke
DISEASE
and within a few minutes she became moreresponsive opening eyes spontaneously. By the time neuro cameto bedside pt was able to verbalize her name and was noted tobe using the right arm and had left sided deficit. A CODE
stroke
DISEASE
was called and pt was taken for urgent CTA head which didnot show any
vessel obstruction
DISEASE
and TPA was felt unlikely to behelpful. Perfusion images confirmed right temporal
hypoperfusion
DISEASE
consistent with clinical exam and likely right MCA
infarct
DISEASE
. ICU consult was initiated and pt's guardian wasnotified. Pt was given Vanc/Cefepime and Aspirin 300mg PR whileawaiting ICU transfer. She was lying flat per neuro recs andwas noted to be spitting up
bilious emesis
DISEASE
. Head of bed waselevated and pt was suctionned prior to transferred to the ICUfor closer monitoring of airway and management of acute
pneumonia
DISEASE
.Past Medical History:
Hypertension
DISEASE
Developmental Delay
Mirizzi Syndrome
DISEASE
COPD
DISEASE
Social History:At baseline pt lives at a nursing home and is able to feedherself undress and can transfer from chair to bed but isotherwise wheelchair bound. No smoking/ETOH history documented.Family History:none relevant to this hospitalization.Physical Exam:Admission:T 101 BP 152/86 HR 86 RR 30 Sats 94%
RA
DISEASE
GEN: somnolent open eyes to vigorous stimulousHEENT: Eyes deviated to right tracks to left with startleCV: RRR no apprec mRESP: diffuse expiratory wheezes moving air wellABD: soft [**Month (only) **] BS no rebound/guardingGU: foley in placeEXTR: warm minimal
edema
DISEASE
toes upgoingNEURO: minimally responsive eyes deviated no withdrawal topainful stimuliPertinent Results:[**2182-10-17**] 04:02PM BLOOD WBC-24.8*# RBC-6.40* Hgb-13.9 Hct-43.8MCV-68* MCH-21.6* MCHC-31.6 RDW-14.3 Plt Ct-273[**2182-11-2**] 05:55AM BLOOD WBC-8.1 RBC-5.33 Hgb-11.8* Hct-38.1MCV-72* MCH-22.2* MCHC-31.0 RDW-14.8 Plt Ct-399[**2182-11-1**] 06:05AM BLOOD Glucose-113* UreaN-4* Creat-0.5 Na-141K-3.5 Cl-106 HCO3-27 AnGap-12[**2182-10-28**] 06:05AM BLOOD Calcium-9.8 Phos-3.5 Mg-1.9[**2182-10-17**] 04:02PM BLOOD ALT-92* AST-118* AlkPhos-247* TotBili-1.4[**2182-10-18**] 04:42AM BLOOD ALT-145* AST-277* AlkPhos-136*Amylase-101* TotBili-0.5[**2182-10-28**] 06:05AM BLOOD ALT-50* AST-46* LD(LDH)-170 AlkPhos-144*TotBili-0.3[**2182-10-21**] 06:36AM BLOOD Triglyc-143 HDL-44 CHOL/HD-3.8 LDLcalc-93[**2182-10-21**] 06:36AM BLOOD %HbA1c-9.4* eAG-223*.ERCP [**2182-10-17**]Procedures: A plastic stent was removed.Impression: 2 balloon sweeps were performed with a small stonesludge and debris removed. A 1.5 cm
biliary stricture
DISEASE
in mid-CBDcompatible with known
cystic duct stone
DISEASE
and
mirrizi syndrome
DISEASE
wasvisualized. A 10 F 5cm double pigtailed catheter was placed.Otherwise normal ercp to third part of the duodenum.CXR [**2182-10-17**] IMPRESSION:
Right lower lobe pneumonia
DISEASE
with
atelectasis
DISEASE
or
pneumonia
DISEASE
at the left base..CTA HEAD W&W/O C & RECONS IMPRESSION: Moderate-to-severe
intracranial atherosclerotic disease
DISEASE
with findings suggestive ofdecreased perfusion to the right MCA/PCA watershed region. Thefindings may represent
cerebral ischemia
DISEASE
in the setting of
hypovolemia hypotension
DISEASE
or other causes of decreased cardiacoutput..Cardiac Echo: IMPRESSION: Small LV cavity size with mildsymmetric
LVH
DISEASE
and hyperdynamic LV systolic function.Consequently there is a mild to moderate LV outflow tractgradient. No pathologic
valvular abnormality
DISEASE
seen..RUE LENI IMPRESSION: Partially
occlusive thrombus
DISEASE
in the rightbasilic and axillary veins at site of PICC line. Clot does notextend more centrally..ABDOMEN (SUPINE ONLY) PORT IMPRESSION: Limited view of theabdomen demonstrating no evidence for
obstruction
DISEASE
. Bladderstone.Coags:[**2182-11-1**] 06:05AM BLOOD PT-13.4 PTT-29.7 INR(PT)-1.1[**2182-11-2**] 05:55AM BLOOD PT-14.0* INR(PT)-1.2* (Started Warfarin5 mg)Brief Hospital Course:77 y/o F with PMhx of Developmental
Delay COPD HL HTN
DISEASE
and
Mirizzi syndrome
DISEASE
who presented on [**10-17**] for elective ERCP. Ptwas noted to have
emesis
DISEASE
on her gown in the post procedure suitewith diffuse wheezes and low grade temp. It was thought likelythat she had an aspiration event and when she was arrived on thefloor she had a profoundly
depressed
DISEASE
mental
status tachypnea
DISEASE
and
fever
DISEASE
to 101.9. Further stat work up revealed evidence ofaspiration PNA
leukocytosis
DISEASE
and elevated lactate. Initial headimaging was unrevealing. However she became more alert and wasnoted to have an acute left sided deficit. CODE STROKE wascalled and CTA/perfusion images confirmed right sided
hypoperfusion
DISEASE
likely consistent with right MCA stroke. Neurofelt there was no indication for TPA given patent intracranialvessels and on return to the floor pt was noted to have
bilious
DISEASE
secretions that she was having difficulty clearing. She wastransferred to the ICU for airway monitoring overnight. Pt wascalled out to the floor when she was able to
cough
DISEASE
and spit upsecretions. She was noted to have a waxing and [**Doctor Last Name 688**] mentalstatus sometimes will respond to commands and other times willnot. BP was allowed to autoregulate for the first 72 hrs postevent and pt was continued on Aspirin 300mg daily. She wasnoted to have recovery of left arm function and was answeringyes/no to questions.She was seen by PT/OT who recommended ongoing therapy uponreturn to NH.After discussion with HCP/guardian decision was made to avoidfollow up MRI as it was not likely to change care plan and ptwas unlikely to tolerate the procedure. Echo was performed torule out
cardioembolic
DISEASE
source which did not show any
thrombus
DISEASE
.Lipid panel showed LDL in the 93 and Hgb A1c 9.4. She washyperglycemic during the hospitalization and she was started onLantus and sliding scale insulin..Aspiration PNA: Pt was noted to have aspiration event s/pprocedure and was monitored in the ICU for 24hrs given concernfor her ability to protect airway . Leukocytosis lactate and
fevers
DISEASE
resolved after initiation of Vanc/Cefepime/Flagyl.Respiratory status improved and pt had a PICC placed and shecompleted a course of antibiotics.Upper Extremity DVT- Patient was subsequently developed a
DVT
DISEASE
associated with the PICC line. The PICC line was discontinuedand she was started on Lovenox. Once a PEG tube was placed shewas started on Warfarin for a goal INR of [**2-6**]. Please followINR closely and titrate prn. She received her first dose ofWarfarin 5 mg on [**11-2**].Aspiration - Pt was seen by speach/swallow on multipleoccasions which she grossly failed with aspiration. She waskept strictly NPO and she was maintained with IV medicationsand hydration. A dobhoff was placed for initiation of tubefeeds while waiting to see if she would regain her swallowfunction. It is/was hoped that her swallow function wouldimprove especially considering her significant recovery in herleft arm movement however she did not show significantimprovement on serial exams. In discussion with Speech andSwallow however there is some hope that she may recover herswallow on a long term basis and Swallow therapy may help withthis recovery. They suggested an approximate 50% chance ofrecovery to the point of safe oral intake in the long-term..Diabetes-Pt with uncontrolled
hyperglycemia
DISEASE
after the initiationof tube feeds. Her lantus and insulin sliding scales wereagressively increased. She is being discharged on 70 units oflantus and a sliding scale..
Mirizzi Syndrome
DISEASE
s/p ERCP: Pt with
abnormal biliary anatomy
DISEASE
whounderwent stent and sphincteroplastyon [**10-17**] for recurrent abd
pain
DISEASE
. She was noted to have an acute rise in transaminases postprocedure and these trended down with normal Tbili. Pt wasfollowed by ERCP team while in house..Developmental Delay: baseline confirmed with her guardian/motherand nursing home..
HTN
DISEASE
: held BP meds to allow autoregulation s/p
stroke
DISEASE
. She wassubsequently treated with IV metoprolol clonidine patch and IVlasix with benefit. After obtaining access via PEG a bloodpressure medication regimen via PEG was begun. I expect that shewill benefit from further titration of medications as anoutpatient. Please note that she was also started onLisinoprilAdmission Date: [**2197-6-15**] Discharge Date: [**2197-6-16**]Date of Birth: [**2155-12-29**] Sex: FService: MEDICINE
Allergies
DISEASE
:Bactrim / Trazodone / Indinavir / Flovent HFA / LMA maskAttending:[**First Name3 (LF) 3984**]Chief Complaint:
hypoxia
DISEASE
Major Surgical or Invasive Procedure:endotracheal intubationlaser vaporization of the vulvaHistory of Present Illness:The patient is a 41-year-old femalewith past medical history of HIV/AIDS (CD4 392 and viral loadundetectable in [**2197-5-2**]) on Atripla history of
depression/anxiety hypertension chronic kidney disease
DISEASE
cervical and vaginal dysplasia
DISEASE
and
laryngeal papillomatosis
DISEASE
aswell as abnormal urinary cytology admitted to the ICU followinglaser vaporization of the
vulva
DISEASE
complicated by immediate post-op
desaturation
DISEASE
on waking up intubated in OR.Per report the procedure went well without complication. She wasin her normal state of health prior to the procedure. Intra-opshe received a total of 2L of fluid intraoperatively. An LMA wasused. Towards the end of the case she was noted to movesuddenly. She was given a bolus dose of propofol. Following thecase she was able to breath on her own for 5-1o mintues she thenbecame aggressive and bit down on the LMA disloging the tube.This was followed by an acute desaturation to the 70-80s. Shewas given more propofol for sedation and mask ventilated withsome difficulty. She was intubated with blood noted in the tube. Over the course of an hour she was noted to be much easier toventilate on exam lungs were noted to clear. She was thentransferred to the [**Hospital Unit Name 153**] for further management.On arrival to the MICU patient's VS 92.4 59 97/71 12 100% SpO2CMV Vt 500 mL PEEP of 10. Patient was intubated and sedated withblood noted in the ET tube.Review of systems:unable to obtainPast Medical History:1. HIV diagnosed in [**2177**] at the time of bilateral lobar
pneumonia
DISEASE
complicated by
ARDS
DISEASE
. Risk factor heterosexual sex.CD4 nadir reportedly 186.2. Cocaine abuse clean since [**2180**]Admission Date: [**2201-2-10**] Discharge Date: [**2201-2-17**]Date of Birth: [**2143-10-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:Codeine / Streptokinase / IodineAttending:[**First Name3 (LF) 3991**]Chief Complaint:Left Total Knee ReplacementMajor Surgical or Invasive Procedure:Left Total Knee ReplacementHistory of Present Illness:57-year-old male with a past medical history significant forsevere bilateral
arthritis
DISEASE
S/P R TKR in [**10-8**]Admission Date: [**2201-8-19**] Discharge Date: [**2201-8-25**]Date of Birth: [**2143-10-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:Codeine / Streptokinase / Iodine / Bee PollensAttending:[**First Name3 (LF) 3991**]Chief Complaint:
Shortness of breath
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:57M with
AF
DISEASE
on coumadin h/o dvt
CHF
DISEASE
CAD h/o MI
COPD
DISEASE
on 4Lhome O2 4 prior intubations for PNA who presented with 4d ofworsening SOB. He was admitted at [**Hospital3 3583**] approximately5 wks ago for PNA and intubated for approximately 6 days. Atbaseline he takes 160mg Lasix TID. He began to feel short ofbreath 4 days prior to admission at [**Hospital1 18**] with
orthopnea
DISEASE
mild
cough
DISEASE
with one episode of coughing up brown non-bloody sputumand
fever
DISEASE
to 100 on the morning of admission with no priorknown
fevers
DISEASE
. He reports
weight loss
DISEASE
of 20lb over the past fewweeks and more than 80lbs over the past year secondary to poorappetite. He denied any recent sick contact/travel missedmedication doses or dietary alterations.In the ED initial vs were T 97.6 HR 120 BP 186/103 RR 20 sat96% 5L. Prior to transfer to ICU vs were HR 108 afib BP131/101 RR 15 95% on 5L. The patient was givenvanco/ceft/azithro (without cultures) nebs and K repletion.CXR showed
cardiomegaly
DISEASE
bilateral
pleural effusions
DISEASE
RAdmission Date: [**2201-8-28**] Discharge Date: [**2201-9-15**]Date of Birth: [**2143-10-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:Codeine / Streptokinase / Iodine / Bee PollensAttending:[**Last Name (NamePattern1) 1167**]Chief Complaint:
Shortness of breath
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:57M with PMH of
atrial fibrillation
DISEASE
on coumadin systolic Admission Date: [**2155-7-4**] Discharge Date: [**2155-7-8**]Date of Birth: [**2082-11-22**] Sex: MService: Blue SurgeryHISTORY OF PRESENT ILLNESS: Briefly this is a 72-year-oldmale who is status post repair of a left inguinal
hernia
DISEASE
on[**2155-6-26**] who had been discharged home later in the day whohad been feeling well until one day prior to admission whenhe began to have
fevers
DISEASE
up to 101 and also had some chestpressure. He saw Dr. [**Last Name (STitle) 957**] in the office who wasconcerned and sent the patient to the Emergency Room forevaluation. He denies
chest pain shortness
DISEASE
of breath
nausea vomiting diarrhea
DISEASE
or any other symptoms.PAST MEDICAL HISTORY:1.
Prostate cancer
DISEASE
status post prostatectomy.2.
Hypertension
DISEASE
.ALLERGIES: Erythromycin.MEDICATIONS:1. Triamcinolone.2. Lipitor.3. Zestril.4. Terazosin.5. Allopurinol.SOCIAL HISTORY: He does not smoke and he does not drink.PHYSICAL EXAMINATION: On physical exam he is afebrile withvital signs stable. He was in no apparent distress. Hislungs were clear to auscultation bilaterally. His heart wasregular rate no murmurs rubs or gallops. His abdomen wassoft nontender nondistended with normoactive bowel sounds.Incision was clean dry and intact.LABORATORIES: His white count was 4.9 hematocrit of 43.7platelet count of 182. Urinalysis was negative.
Chemistries
DISEASE
: Sodium was 134 potassium 3.9 chloride of 102bicarb of 26 BUN 18 creatinine of 1.3 blood sugar of 108CK of 72 troponin was less than 0.3.He had a CTA to rule out
pulmonary embolus
DISEASE
which was negativeand a chest x-ray which showed no
pneumonia
DISEASE
and only somemild
atelectasis
DISEASE
.Patient was admitted to the Intensive Care Unit formonitoring and planned evaluation. Upon admission to theEmergency Room he had a temperature spike to 104 with
fevers
DISEASE
and
chills
DISEASE
. He had blood cultures done at that time whichultimately grew nothing. He was started on broad-spectrumantibiotics Vancomycin gentamicin and Flagyl and wascultured.On hospital day #2 he was changed to Vancomycin levo andFlagyl and he continued to improve. His white count wasnormal throughout his entire hospital admission. Histemperature max on hospital day #2 was 104.5. His primarycare doctor also saw him and suggested a lower extremityultrasound to rule out
DVT
DISEASE
which was done and was negative.His platelet count began to drop on [**7-6**]. His Heparin wasstopped and a
HIT
DISEASE
antibody was sent which is pending at thetime of discharge............... was consulted for evaluation of mastoids. Ahead CT scan was done on [**2155-7-6**] which showed fluid in hisleft mastoid air cell. It was felt that this was unlikelycause of his
fevers
DISEASE
and is instructed to followup the [**Hospital **]Clinic if necessary.Patient was transferred to the floor on [**2155-7-6**] and wasstable. On hospital day #4 his temperature which had beenthe highest at 104.5 was down to 100.4 and he continued todo well. He was allowed to eat a regular diet. His plateletcount dropped again and his Vancomycin was stopped.On [**2155-7-8**] his platelet count and white blood cell counthad elevated after his Heparin was stopped. His
HIT
DISEASE
wasstill pending at that time and the Vancomycin had beenstopped for a fear of his
pancytopenia
DISEASE
.On hospital day #5 he was afebrile now for 72 hours and itwas felt safe that he could be discharged home. He iscontinued on levo/Flagyl for seven more days and instructedto followup with Dr. [**Last Name (STitle) 957**] in [**2-6**] weeks as well as followup with his primary care physician.PRESCRIPTION MEDICATIONS:1. Protonix 40 mg po q day.2. Theophylline sustained release 200 mg po q day.3. Levofloxacin 500 mg po q day.4. Flagyl 500 mg po tid.DISCHARGE INSTRUCTIONS: Instructed to continue all of hishome medications as normal and patient was discharged homein stable condition on [**2155-7-8**].FOLLOW-UP INSTRUCTIONS: Patient is to followup with Dr.[**Last Name (STitle) 957**] as well as his primary care doctor.DISCHARGE DIAGNOSES:1.
Fever
DISEASE
now on antibiotics levofloxacin and Flagyl.2.
Pancytopenia
DISEASE
now off Heparin and resolving.3.
Prostate cancer
DISEASE
status post prostatectomy.4.
Hypertension
DISEASE
.5. Left inguinal
hernia
DISEASE
status post left inguinal herniarepair.CONDITION ON DISCHARGE: Stable. [**Name6 (MD) **] [**Name8 (MD) **] M.D. [**MD Number(1) 4007**]Dictated By:[**First Name (STitle) 4008**]MEDQUIST36D: [**2155-7-8**] 08:57T: [**2155-7-8**] 08:59JOB#: [**Job Number 4009**]Admission Date: [**2181-7-17**] Discharge Date: [**2181-7-20**]Date of Birth: [**2125-8-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:lisinoprilAttending:[**First Name3 (LF) 602**]Chief Complaint:
Dyspnea
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:55M with history of
HTN GERD
DISEASE
and
asthma
DISEASE
presenting with 7 daysof worsening SOB and
cough
DISEASE
productive of thick occasionallybrown sputum. Initially with sinus/congestion symptoms last weekwhich since resolved but now with respiratory symptoms. Hasbeen taking albuterol hfa/nebs without significant relief. Hetakes fluticasone INH [**Hospital1 **] as control medicationAdmission Date: [**2131-10-20**] Discharge Date: [**2131-11-4**]Date of Birth: [**2050-1-1**] Sex: FService: MEDICINE
Allergies
DISEASE
:Levofloxacin / AllopurinolAttending:[**First Name3 (LF) 759**]Chief Complaint:Bilateral
hip pain
DISEASE
Major Surgical or Invasive Procedure:Left hip hemiarthroplastyRight hip ORIFIntubationPICC placementHistory of Present Illness:81 yo woman with PMH signficant for
SLE gout CHF
DISEASE
and MVRsevere
osteoporosis
DISEASE
who was admitted on [**2131-10-11**] to [**Location (un) **][**Location (un) 1459**] from NH c/o bilateral
hip pain
DISEASE
. She denied
trauma
DISEASE
buthad an overlying
hematoma
DISEASE
on the right side however she doesnot Admission Date: [**2132-8-3**] Discharge Date: [**2132-8-8**]Date of Birth: [**2053-2-6**] Sex: FService: MEDICINE
Allergies
DISEASE
:Demerol / Lovastatin / Levaquin / Gentamicin / Iodine ContainingAgents ClassifierAttending:[**First Name3 (LF) 1666**]Chief Complaint:Increased sputum worsening SOBMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:79F Russian speaking hx of
Pulmonary MAC
DISEASE
(Mycobacterium aviumcomplex diagnosed in [**2128**]) on standing clarithromycinethambutol and rifampin complicated by
bronchiectasis
DISEASE
followedby Dr. [**Last Name (STitle) 575**]. Who presents with worsening of
breath cough
DISEASE
and sputum production for 2 weeks worse over the last two days.Patient reports increasing
cough
DISEASE
productive of yellow/clearsputum without associated
fevers
DISEASE
or
chills
DISEASE
. Confirms some
post-tussive pain
DISEASE
and occassional
post-tussive nausea
DISEASE
. Patientalso denies night sweats however reports increased
weight loss
DISEASE
over the past months..Of note patient recently seen [**Doctor Last Name 575**] in clinic on [**2132-7-29**]and was started on Cefaclor one 500 mg capsule 3 x a daily fora week for increasing sputum production although she has beennoncompliant due to
nausea
DISEASE
and
vomiting
DISEASE
. She has also beenunable to use Acupella as it gives her
headache
DISEASE
. Patient had a[**2132-7-29**] Chest CT Scan at the time that revealed generalizedprogression of widespread small
airway bronchiectasis
DISEASE
and
bronchiolitis
DISEASE
..She returned to the ED on [**2132-8-3**] with increasing sputumproduction and difficulty breathing. She has had this for 2weeks. Vitals in the ED were 97.2 Labs were notable for WBC of16 and sodium of 109 (baseline 135). She was given 1 dose ofCTX. CXR revealed worsening
small airways disease
DISEASE
consistentwith patient's history of MAC.Past Medical History:1.
Pulmonary MAC infection
DISEASE
with tree-in-[**Male First Name (un) 239**]
opacities
DISEASE
and
bronchiectasis
DISEASE
now on antibiotics nearly continuously since[**Month (only) 205**][**2128**]. Has been on triple therapy since [**2128**]2. Significant head
tremor
DISEASE
- worsened with albuterol & flovent3. Lower
airway colonization
DISEASE
with
pseudomonas
DISEASE
.4.
Obstructive airways disease
DISEASE
.5.
Hypertension
DISEASE
.6. GERD.7.
Weight loss
DISEASE
.8.
Headaches
DISEASE
.9. Possible Levaquin and or Zithromax
allergy
DISEASE
.10.
Hyperlipidemia
DISEASE
Social History:Denies alcohol or tobacco useAdmission Date: [**2132-8-26**] Discharge Date: [**2132-9-2**]Date of Birth: [**2053-2-6**] Sex: FService: MEDICINE
Allergies
DISEASE
:Demerol / Lovastatin / Levaquin / Gentamicin / Iodine ContainingAgents ClassifierAttending:[**First Name3 (LF) 1436**]Chief Complaint:
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:History of Present Illness: Patient is a 79 y/o Russianspeaking female with a hx of
Pulmonary MAC
DISEASE
diagnosed in [**2128**] onstanding clarithromycin ethambutol and rifampin complicated by
bronchiectasis
DISEASE
who presented from home with worsening shortnessof
breath cough
DISEASE
and sputum production for 2 days. Patientreports that yesterday her breathing started becomming moredifficult with increased
cough
DISEASE
productive of yellow/clear sputumwithout associated
fevers
DISEASE
or
chills
DISEASE
. Her breathing improvedwith clearing of her secretions however this morning she wasunable to produce any
phlegm
DISEASE
and her breathing became much more
labored
DISEASE
. She presented to the ED due to worseing SOB. Shedenies recent
chest pain pleuritic pain nausea vomiting
DISEASE
or
diarrhea
DISEASE
. Per her husband she has had less energy and decreasedappetite since her last hospitalization however her breathinghad been stable until 2 days ago. Patient denies night sweatshowever reports increased
weight loss
DISEASE
over the past months..Of note patient was recently admitted to [**Hospital1 18**] on [**8-3**] withsimilar complaints. Imaging at that time showed progression ofwidespread small
airway bronchiectasis
DISEASE
and
bronchiolitis
DISEASE
. Shewas admitted to the ICU however did not require intubation orsteroids. She completed 5 days of cefepime per IDrecommendations and completed an additional 10 day course ofcefpodoxime 200mg po BID for presumed CAP..In the ED VS initially showed T 96.7 BP 149/84 HR 89 RR 28-48 O2sat 97% on
RA
DISEASE
. CXR showed interval improvement in themultifocal patchy
opacities
DISEASE
previously noted. She was given onedose of cefepime and ASA 325mg x1. She was placed on oxygen forcomfort and then desaturated into the 80's and was placed on
NRB
DISEASE
with inc. in her oxygen sat to 100% however she remainedtachypneic. Due to inability to wean off NRB she was admittedto the ICU for further treatment.Past Medical History:1.
Pulmonary MAC infection
DISEASE
with tree-in-[**Male First Name (un) 239**]
opacities
DISEASE
and
bronchiectasis
DISEASE
now on antibiotics nearly continuously since[**Month (only) 205**][**2128**]. Has been on triple therapy since [**2128**]2. Significant head
tremor
DISEASE
- worsened with albuterol & flovent3. Lower
airway colonization
DISEASE
with
pseudomonas
DISEASE
- recentlycompleted course of cefepime/cefpodoxime (unclear how diagnosisof
colonization
DISEASE
made)4.
Obstructive airways disease
DISEASE
.5.
Hypertension
DISEASE
.6. GERD.7.
Weight loss
DISEASE
.8.
Headaches
DISEASE
.9. Possible Levaquin and or Zithromax
allergy
DISEASE
.10.
Hyperlipidemia
DISEASE
Social History:Denies alcohol or tobacco useAdmission Date: [**2195-3-7**] Discharge Date: [**2195-3-11**]Date of Birth: [**2148-5-10**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4028**]Chief Complaint:
Abdominal pain hypothermia
DISEASE
Major Surgical or Invasive Procedure:1) Arterial line2) Central venous line /femoral line3) Patient continued his usual peritoneal dialysis sessionsHistory of Present Illness:Mr. [**Known lastname 122**] is a 46 year-old male with
HIV Hepatitis B/C ESRD
DISEASE
on peritoneal dialysis who presented to the ED with abdominal
pain constipation
DISEASE
and also feeling dizzy with lightheadedness.Called the ambulance for these symptoms. Initial VS 91.1Forally HR 72 BP initially unmeasurable RR 20 and 100% oxygensaturation on room air. Exam with clear lungs RRR distendedabdomen which was soft and full. He refused a rectal exam. CTwas obtained given
abdominal pain
DISEASE
and preliminary read wasnegative for any acute intrabdominal processes. Right femoralline was placed with some difficulty due to scar tissue. BPremained difficult to assess given severe
vascular disease
DISEASE
.Repeat VS soon after presentation revealed temperature 96.1F75HR BPs of 59/25-105/47 RR 12 and oxygen saturation was 100%room air. Fingerstick glucose was 123. Patient had potassiumrepleted with 40 mEq K in 1L NS with 3 additional L NS. Hisperitoneal dialysate was sampled and did not reveal evidence of
infection
DISEASE
. Denies ever having
abdominal pain
DISEASE
but more a senseof
constipation
DISEASE
and Admission Date: [**2132-9-4**] Discharge Date: [**2132-9-9**]Service: MED
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1055**]Chief Complaint:1. SOB x 1 week2. intermittent black stool for 6 monthsMajor Surgical or Invasive Procedure:Upper EndoscopyColonoscopyHistory of Present Illness:This is an 80 yo F who presents to the ED with SOB and LE
edema
DISEASE
x1 week. On arrival to the ED she was unable to speak in fullsentences and was
wheezing
DISEASE
. On further questioning she claimsthat she had not been taking her usual dose of lasix for oneweek. Her presciption had ran out.She also notes a 6 month history of intermittent black stool.She has discussed this with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Her most recentoccult blood in [**2132-8-20**] was negative and according to Dr. [**Last Name (STitle) **]the stool was brown not black as she describes it. Patient alsoclaims that she has occasional BRBPR on straining with BMs witha history of
hemorrhoids
DISEASE
. She is on a daily ASA and deniesother NSAID use. She has no history of alcohol consumption.Denies abd pain/nausea/vomitting/hemetemesis.On ROS she denies chest pain/fever/ chills/changes in bowel
habit/headache/hemeturia/changes
DISEASE
in diet.Past Medical History:1. DM II2.
HTN
DISEASE
3.
pulmonary hypertension
DISEASE
4. increased cholesterol5. chroninc low back
pain
DISEASE
and
sciatica
DISEASE
Social History:Denies ETOH IVDA or tob use.Physical Exam:BP 150/58 P70Gen: comfortable pale elderly Russian speaking female lying inbed in NAD.HEENT: PERRL. Anicteric. MMM. Pale conjunctivaNeck: Supple. No masses or LAD. JVD 8-10 cm.Lungs: diffuse crackles.Cardiac: RRR. S1/S2. II/VI systolic M heard best at apex.Abd: Soft obese NT ND Admission Date: [**2197-5-16**] Discharge Date: [**2197-5-19**]Date of Birth: [**2148-5-10**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 613**]Chief Complaint:
Hypothermia
DISEASE
altered mental statusMajor Surgical or Invasive Procedure:noneHistory of Present Illness:49M with HBV HCV and
ESRD
DISEASE
[**1-11**] HIV on dialysis for 25 yearspresents with purulent drainage from around the peritonealdialysis catheter with an exposed cuff. He dialyzes himself athome and follows up at [**Hospital 4029**] Clinic sporadically. He presentedto [**Hospital 4029**] Clinic today and was sent to [**Hospital1 18**] ED for the exposedcatheter cuff and exit site
infection
DISEASE
. The peritoneal dialysiscatheter is working and he reports clear output.The patient denies
fevers chills nausea
DISEASE
vomitting abdominal
pain diarrhea
DISEASE
. He does not
recall last bowel movement
DISEASE
. Hereports decreased appetite and
weight loss
DISEASE
but unsure how much.He was dialyzed last night.The patient is a very poor historian. There is a note in hispaperwork from [**Last Name (un) 4029**] that he was admitted to [**Hospital1 336**] from [**2197-5-4**]to [**2197-5-9**] but it does not state why. The patient reports thatit was for
infection
DISEASE
of his peritoneal dialysis catheter and hewas treated with antiobiotics.On initial evaluation in the ED the patient was reportedly verysomnolent and unresponsive to sternal rub but then arousedwithout intervention and was able to answer questions. CD4count was 273 2 years ago and the patient is reportedlynon-compliant with his medications.Past Medical History:* HIV- diagnosed HIVAdmission Date: [**2195-10-31**] Discharge Date: [**2195-11-4**]Service: NEUROLOGYHISTORY OF PRESENT ILLNESS: [**Known firstname 4036**] [**Known lastname **] is a 58 year-oldright handed male with a past medical history significant forpresented to the Emergency Department on [**2195-10-30**] in theevening complaining of acute onset of left sided weakness.The patient reports that he had been sitting on his couch at11:30 p.m. on the 23rd when he suddenly felt lightheaded anddizzy. He did not really feel that he was particularly weakor
numb
DISEASE
on one side or the other. He denied any
headache
DISEASE
orchanges in vision at that time. His family however notedOn arrival to the Emergency Department he was evaluated andnoted to be dysarthric and he had mild left face arm and leg
weakness
DISEASE
and
left sided neglect
DISEASE
. An acute MRI revealed subtleDWI changes in the right lenticulo- striate arterial territorysuggestive of early
ischemia
DISEASE
. A MRA showed possible mild stenosisof the distal M1 segment. While in the MRI scanner his weaknessclearly became worse. He was given TPA at 1:43 a.m. Thisdid not seem to improve his clinical examination. He waskept for observation in the Neurology Intensive Care Unit.His course there was uneventful. He was transferred to the flooron the 25th.On exam on the neurology floor:BP was 130/75 HR 74 RR 14He was AO x 3On CN exam had a right lower face weaknessMotor was 1-2/5 in the right arm and3-4/5 in the lower extremityDTR were [**Name2 (NI) 4037**]Positive
Babinski
DISEASE
's sign on the rightHospital courseThe patient underwent a carotid ultrasound which showed nosignificant
stenosis
DISEASE
in the right or left carotid arteries.The patient also underwent a transthoracic echocardiogramwhich showed excellent left ventricular ejection fractiongreater then 55% and no potential source for
embolus
DISEASE
. Thepatient was evaluated by physical therapy and occupationaltherapy and decided the best place for him to be dischargedto was acute rehabilitation. At the time of discharge thepatient was almost completely paretic in the left upperextremity. He still had a
left facial droop
DISEASE
and had regainedsome function in his left lower extremity.Of significance the patient was started on aspirin 81 mg po qday and Aggrenox one tab po b.i.d. on the 25th.DISCHARGE MEDICATIONS: In addition to the aspirin andAggrenox Lipitor 10 mg po q day insulin as the patient is a
diabetic
DISEASE
.The patient will be discharged on a ground solid thin liquiddiet as per speech and swallow. The patient needs to followup in [**Hospital 4038**] Clinic in one months time.[**Name6 (MD) 725**] [**Name8 (MD) 726**] M.D. [**MD Number(1) 727**]Dictated By:[**Last Name (NamePattern1) 4039**]MEDQUIST36D: [**2195-11-4**] 11:53T: [**2195-11-4**] 11:56JOB#: [**Job Number 4040**]Admission Date: [**2187-12-24**] Discharge Date: [**2187-12-28**]Date of Birth: [**2108-9-21**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 1505**]Chief Complaint:
Chest pain lightheadedness
DISEASE
and dsypnea on exertionMajor Surgical or Invasive Procedure:[**2187-12-24**] - Aortic valve replacement (21mm St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 4041**]tissue valve)/Coronary artery bypass grafting x 1 (Left internalmammary artery-Admission Date: [**2156-8-1**] Discharge Date: [**2156-8-12**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 358**]Chief Complaint:epigastric/chest
pain
DISEASE
Major Surgical or Invasive Procedure:ERCP with stent placement no sphincterotomy seconary tosupratheraputic INRHistory of Present Illness:HPI: 87yo man with h/o CAD s/p CABG [**2141**] mult PCI sinceischemic CMY with LVEF 35%
Afib
DISEASE
on coumadin possible AS and/orMR diet controlled
DM2
DISEASE
Admission Date: [**2171-9-26**] Discharge Date: [**2171-10-1**]Date of Birth: [**2095-11-14**] Sex: FService: MEDICINE
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 12**]Chief Complaint:sdfsdaMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:[**Known lastname 4048**] is a 75 y.o. female with pertinent history of MDS x 2years chronic
anemia
DISEASE
requiring blood transfusions (lasttransfusion 1 wk prior to admission) and recent admission formelanotic stools w/ neg GI workup. Pt was recently discharged[**9-16**] from [**Hospital1 **] following admission for
GIB
DISEASE
and subsequentstabilization w/o intervention. Following discharge reports thatshe was feeling tired and weak with decreased appetite. Admission Date: [**2114-4-3**] Discharge Date: [**2114-4-13**]Date of Birth: [**2047-10-15**] Sex: MService: Cardiac SurgeryCHIEF COMPLAINT: Unstable
angina
DISEASE
.HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 23**] is a 66-year-oldmale with a past medical history of
coronary artery disease
DISEASE
type 2 diabetes mellitus hypertension
DISEASE
and
hypercholesterolemia
DISEASE
who came to [**Hospital1 190**] with
unstable angina
DISEASE
.He was in his usual state of health and doing well withcardiac rehabilitation until about one week ago when he hadtwo episodes of
chest pain
DISEASE
. He cardiologist had increasedhis Zestril from 2.5 mg to 5 mg and his atenolol to 150 mgp.o. q.d. The patient continued with cardiac rehabilitationuntil the a.m. of admission (which was [**2114-4-3**]) whenhe had two episodes of resting
angina
DISEASE
at 1:15 a.m. and at3 a.m. relieved by one sublingual nitroglycerin. He wasreferred to cardiac catheterization for his
unstable angina
DISEASE
.PAST MEDICAL HISTORY: (His past medical history includes)1.
Coronary artery disease
DISEASE
. He had a cardiaccatheterization in [**2113-12-19**] with percutaneoustransluminal coronary angioplasty and stent of the leftanterior descending artery and the first obtuse marginal. Hehad a catheterization in [**2114-1-19**] with percutaneoustransluminal coronary angioplasty of first obtuse marginal
in-stent stenosis
DISEASE
and subsequent brachy treatment with stentsplaced distal and proximal to the first obtuse marginal.2. Type 2
diabetes
DISEASE
mellitusAdmission Date: [**2114-4-3**] Discharge Date: [**2114-4-13**]Date of Birth: [**2047-10-15**] Sex: MService: Cardiac SurgeryCHIEF COMPLAINT: Unstable
angina
DISEASE
.HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 23**] is a 66-year-oldmale with a past medical history of
coronary artery disease
DISEASE
type 2 diabetes mellitus hypertension
DISEASE
and
hypercholesterolemia
DISEASE
who came to [**Hospital1 190**] with
unstable angina
DISEASE
.He was in his usual state of health and doing well withcardiac rehabilitation until about one week ago when he hadtwo episodes of
chest pain
DISEASE
. He cardiologist had increasedhis Zestril from 2.5 mg to 5 mg and his atenolol to 150 mgp.o. q.d. The patient continued with cardiac rehabilitationuntil the a.m. of admission (which was [**2114-4-3**]) whenhe had two episodes of resting
angina
DISEASE
at 1:15 a.m. and at3 a.m. relieved by one sublingual nitroglycerin. He wasreferred to cardiac catheterization for his
unstable angina
DISEASE
.PAST MEDICAL HISTORY: (His past medical history includes)1.
Coronary artery disease
DISEASE
. He had a cardiaccatheterization in [**2113-12-19**] with percutaneoustransluminal coronary angioplasty and stent of the leftanterior descending artery and the first obtuse marginal. Hehad a catheterization in [**2114-1-19**] with percutaneoustransluminal coronary angioplasty of first obtuse marginal
in-stent stenosis
DISEASE
and subsequent brachy treatment with stentsplaced distal and proximal to the first obtuse marginal.2. Type 2
diabetes
DISEASE
mellitusAdmission Date: [**2117-2-15**] Discharge Date: [**2117-2-21**]Date of Birth: [**2047-10-15**] Sex: MService: MEDICINE
Allergies
DISEASE
:Tetracyclines / NiacinAttending:[**Location (un) 1279**]Chief Complaint:
chest pain
DISEASE
Major Surgical or Invasive Procedure:cardiac catheterizationHistory of Present Illness:THis is a 69yo M with h/o CAD
DM2
DISEASE
and
HTN
DISEASE
who presented to theED with
chest pain
DISEASE
. He woke up at 4am on the day of admissionwith left sided sharp 10/10
chest pain
DISEASE
that radiates down hisleft arm. He took nitro with minimal relief.On route to [**Hospital1 18**] onthe ambulance he recieved multiple [**Last Name (un) 4070**] spray which broughtthe
pain
DISEASE
down. He complained of
nausea
DISEASE
but deniesSOB/palpitation/dizziness.On arrival to ED his SBP is 180 with HR 90. He recieved ASAlopressor morphine nitro gtt integrillin and plavix.Concerning with in stent
thrombosis
DISEASE
Past Medical History:1. coronary artery disease-CABG [**2113**]Admission Date: [**2120-10-7**] Discharge Date: [**2120-10-19**]Date of Birth: [**2047-10-15**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Tetracyclines / NiacinAttending:[**First Name3 (LF) 1505**]Chief Complaint:
Dyspnea
DISEASE
on exertionMajor Surgical or Invasive Procedure:[**2120-10-8**] Redo sternotomy Aortic Valve replacement(21mm[**Company 1543**] Mosaic Ultra porcine) Coronary artery bypass graft x1(SVG-PDA)History of Present Illness:Known
coronary artery disease
DISEASE
in 72 year old
diabetic
DISEASE
. He hashad progressive
dyspnea
DISEASE
and arm
pain
DISEASE
with exertion for months.Catheterization in [**Month (only) **] revealed critical
aortic stenosis
DISEASE
([**Location (un) 109**] 0.7cm2) with patent LIMA to LAD 30% lesion of radialartery to ramus graft and an osteal 60%
RCA stenosis
DISEASE
. The veingraft to the obtuse marginal was occluded. He is admitted nowfor valve replacement and possible coronary graft. His Coumadinwas stopped recently and he was admitted for Heparin therapypreoperatively.Past Medical History:insulin dependent
diabetes mellitus
DISEASE
diabeteic
neuropathy
DISEASE
hypothyroidism
DISEASE
lumbar disc disease
DISEASE
paroxysmal atrial fibrilation
obesity
DISEASE
s/p coronary artery bypass graftings/p tonsillectomy
hypertension
DISEASE
dyslipidemia
DISEASE
hearing loss
DISEASE
benign
prostatic hypertrophy
DISEASE
degenerative joint disease
DISEASE
Social History:He lives with his wife in [**Name (NI) 620**].Rare alcohol use and denies any cigarette smoking.He is a retired pharmacist.Family History:
Coronary artery disease
DISEASE
NegAdmission Date: [**2123-11-10**] Discharge Date: [**2123-12-3**]Date of Birth: [**2047-10-15**] Sex: MService: MEDICINE
Allergies
DISEASE
:Tetracycline Analogues / Niacin / Almond Oil / Tree Nut / FruitExtracts / Nafcillin / cefazolinAttending:[**Doctor First Name 3298**]Chief Complaint:
fever rigor vomiting
DISEASE
Major Surgical or Invasive Procedure:TEE [**11-12**] no vegetations EF 40-45%DCCV: [**11-16**] converted to NSRPICC line placed R armTemporary HD line placed R IJ [**2123-11-26**] removed [**2123-12-3**]History of Present Illness:Mr. [**Known lastname 23**] is a 76 yo M with h/o CAD
CHF
DISEASE
a-fib AVR DM HTNHLD p/w one day of
fever
DISEASE
rigor
nausea
DISEASE
and
vomiting
DISEASE
. Pt feltsudden onset rigor one day ago with
fever
DISEASE
to 100 and BPreportedly to 220/120 at home. He had some valium and was ableto sleep. He Of note pt did not have recent sickness no
weight loss
DISEASE
night
sweats
DISEASE
. He did report some exerciseintolerance recently in the gym which he attributed to
hypoglycemia
DISEASE
. Of note pt had a PCI with 2 drug eluting stentsplaced in LAD and R-PDA. Pt had no recent dental work and neverhad colonoscopy.Pt went to [**Hospital1 **] [**Location (un) **] today where he had VS: 102.1 HR: 101 BP:123/49 Resp: 23 O(2)Sat: 100%. Lab showed WBC of 11.3 with 7%Bands INR 3.2 Cr 2.4 CK 1400 CK-MB 6 Trop 0.035Admission Date: [**2134-2-16**] Discharge Date: [**2134-3-9**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 759**]Chief Complaint:
syncope
DISEASE
Major Surgical or Invasive Procedure:R humeral ORIFCervical laminectomyHistory of Present Illness:This is a 81 year old Russian speaking only woman brought fromhome after a
syncopal
DISEASE
episode on day of admission. ThroughRussian interpreter patient states that she had an episode of
chest pain
DISEASE
and
shortness of breath
DISEASE
after lunch and then thinksshe passed out. Patient woke up with a
forehead laceration
DISEASE
andright forearm swelling..In ED
GCS
DISEASE
15 AOx4 FS 130. Patient denied
chest pain
DISEASE
or
shortness of breath
DISEASE
. EKG showed coarse afib vs atach with 2:1block without no acute ischemic changes. Head CT was negativefor
intracranial hemorrhage
DISEASE
and no new
c-spine fracture
DISEASE
on
C-spine
DISEASE
. Hip films show no definite
fracture
DISEASE
. Right arm x-raynegative for
fracture
DISEASE
. CTA to rule out PE in setting CP and
syncope
DISEASE
. [**First Name3 (LF) 1957**] was consulted. Patient rec'd IV morphine and a
tetanus
DISEASE
shot in ED.Past Medical History:1. DM II2.
HTN
DISEASE
3.
pulmonary hypertension
DISEASE
4. increased cholesterol5. chronic low back
pain
DISEASE
and
sciatica
DISEASE
Social History:Patient lives alone. She does not have any stairs at home and isnot able to do stairs and does find that the symptoms aresomewhat worse with prolonged sitting. Patient wears a backsupport corset(belt) compression stocking and uses a walker.Family History:NCPhysical Exam:INITIAL
EXAM
DISEASE
ON MEDICINE SERVICE 97.0 139/58 57 19 96% room airGEN: mild distress lying on back in hard collarHEENT: 2cm laceration on forehead PERRL EOMI tongue no bitemarks laterally slight bruise on tipCV: irregular rate nl S1 S2
II/VI holosystolic murmur
DISEASE
at LLSBno gallopsPULM: CTA anteriorly/laterally wheezeABD: obese soft nontender nondistended Admission Date: [**2124-1-20**] Discharge Date: [**2124-1-25**]Date of Birth: [**2047-10-15**] Sex: MService: MEDICINE
Allergies
DISEASE
:Tetracycline Analogues / Niacin / Almond Oil / Tree Nut / FruitExtracts / Nafcillin / cefazolinAttending:[**First Name3 (LF) 633**]Chief Complaint:Renal
Failure/pneumonia
DISEASE
Major Surgical or Invasive Procedure:PICC line placement.History of Present Illness:76M complicated past medical history including CAD status postCABG s/p stents [**Month (only) **]/[**2122**] (on aspirin and plavix) status postbiologic AVR
CHF
DISEASE
with EF 35-40 % paroxysmal atrial
fibrillation
DISEASE
on coumadin (now off secondary to recent
epistaxis
DISEASE
requiring blood transfusion) history of
strokes CKD
DISEASE
(baselineCr 2.5) with recent
kidney injury
DISEASE
thought to be secondary to
AIN
DISEASE
from naficllin requiring hemodialysis now off. He presented to[**Hospital1 **] with
lethargy
DISEASE
. Patient states that he awoke thismorning feeling unwell. He had no specific or localizing signs.He was recently discharged from [**Hospital3 4103**] on the [**Hospital **] RehabFacility 3 days prior to presentation. He had been there sincean admission to [**Hospital1 18**] for MSSA
bacteremia
DISEASE
complicated by whatappears to be
acute kidney injury
DISEASE
from acute interstitial
nephritis
DISEASE
thought to be secondary to nafcillin. He alsodeveloped diffuse
skin vasculitis
DISEASE
at that time. He had been onsteroids which had been tapered to off about 2 weeks ago. Hehas also had
intermittent delirium
DISEASE
and
volume overload
DISEASE
. Itappears an NSTEMI also complicated his course.He had an episode of
epistaxis
DISEASE
for which he was admitted to[**Hospital1 **] from [**1-1**] to [**1-3**] with an INR greater than 10 at thetime. He is no longer on Coumadin but he is on aspirin andPlavix. He has had no further
bleeding
DISEASE
. He has also had recent
transaminitis
DISEASE
thought to be secondary to amiodarone and statin.He had had a right upper quadrant ultrasounds which did notreveal
acute cholecystitis
DISEASE
but did show
gallstones
DISEASE
in thegallbladder. His amiodarone has been discontinued but itappears he is back on his simvastatin.At [**Hospital1 **] the patient complained of
pain
DISEASE
in his penis fromFoley catheter insertion in the emergency department.He denies
shortness of breath fever chills abdominal pain
DISEASE
nausea vomiting diarrhea chest pain
DISEASE
. He notes a mildnonproductive
cough
DISEASE
over the last few days. He reports hiswhite blood cell count has been elevated intermittently in thepast. It was elevated at NewBridgeAdmission Date: [**2124-2-12**] Discharge Date: [**2124-2-16**]Date of Birth: [**2047-10-15**] Sex: MService: MEDICINE
Allergies
DISEASE
:Tetracycline Analogues / Niacin / Almond Oil / Tree Nut / FruitExtracts / Nafcillin / cefazolinAttending:[**First Name3 (LF) 759**]Chief Complaint:
Dyspnea
DISEASE
Major Surgical or Invasive Procedure:A-line placementHistory of Present Illness:76 y/o male with sCHF (EF 35-40%) AS s/p biologic AVR CADpAF DMII c/b neuropathy
hypothyroidism
DISEASE
and stage III/IV
CKD
DISEASE
with a recent admission for [**Female First Name (un) 564**]
fungemia
DISEASE
who presented from[**Hospital1 **] [**Location (un) 620**] with SOB and altered mental status. He was recentlyhospitalized at [**Hospital1 18**] from [**Date range (1) 4108**] with [**Female First Name (un) 564**]
fungemia
DISEASE
(no evidence of
endophthalmitis
DISEASE
and TEE without evidence of
Endocarditis
DISEASE
) with a hospital course complicated by a left IJ
DVT
DISEASE
(for which he was bridged to Coumadin with Heparin) acuteon CKD (
CKD
DISEASE
[**1-20**]
AIN
DISEASE
most likely [**1-20**] Nafcillin with baselinecreatinine of Admission Date: [**2166-4-11**] Discharge Date: [**2166-4-18**]Date of Birth: [**2119-11-6**] Sex: FService: NEUROSURGERY
Allergies
DISEASE
:Penicillins / Egg / Sulfa(Sulfonamide Antibiotics) /Sulfa(Sulfonamide Antibiotics)Attending:[**First Name3 (LF) 78**]Chief Complaint:
Headache
DISEASE
Major Surgical or Invasive Procedure:cerebral angiogramHistory of Present Illness:This is a 46 year old woman who was a passenger on amotorcycle this evening when she developed severe
headache
DISEASE
atthevertex that she describes as the worst
headache
DISEASE
of her life. Shewas taken to OSH and CT showed
SAH
DISEASE
. She was transferred to [**Hospital1 18**]for further managementPast Medical History:
AIDS
DISEASE
(Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4109**] [**Hospital 1559**] Medical Center)
Hepatitis C
DISEASE
CD4 in 20's viral load 190000
thrombocytopenia
DISEASE
recently seen by Hem/Onc at OSH
depression hypertension
DISEASE
ureteral implants colposcopy IV drug use rotator cuff injury
gallstones
DISEASE
Social History:She formally used IV drugs reports no current ETOH.Reports 3 cigarettes for 1 year. She lives in a sober house. Sheis on disability.Family History:No
aneurysms
DISEASE
Physical Exam:On Admission:: T:98.7 BP: 145/99 HR: 70 R 24 O2Sats 100% 2L NCGen: WD/WN uncomfortable photophobic.HEENT: Pupils: [**2-19**] EOMs intactExtrem: Warm and well-perfused. No C/C/E.Neuro:Mental status: Awake but lethargic somewhat uncooperative withexam. Yelling at examiner.Orientation: Oriented to person place and date.Language: Speech fluent with good comprehension and repetition.Naming intact. No
dysarthria
DISEASE
or paraphasic errors.Cranial Nerves:I: Not testedII: Pupils equally round and reactive to light 2 to 1mm bilaterally.III IV VI:
Extraocular movements
DISEASE
intact bilaterally without
nystagmus
DISEASE
.V VII: Facial strength and sensation intact and symmetric.VIII: Hearing intact to finger rub bilaterally.IX X:
Palatal elevation
DISEASE
symmetrical.[**Doctor First Name 81**]: Sternocleidomastoid and
trapezius
DISEASE
normal bilaterally.XII: Tongue midline without
fasciculations
DISEASE
.Motor: Normal bulk and tone bilaterally. No
abnormal movements
DISEASE
tremors
DISEASE
. Patient not cooperative with exam due to HA movingsymmetrically. No pronator driftSensation: Intact to light touchToes downgoing bilaterallyon the day of discharge:[**2166-5-19**]- deceasedPertinent Results:CTA head [**2166-4-11**]CT angiography of the head demonstrates anapproximately 3.5 mm
aneurysm
DISEASE
arising from the anteriorcommunicating artery at the junction of the right A1 and A2segments and pointing to the left side. No other definite
aneurysms
DISEASE
are identified in the arteries of anterior andposterior circulation.IMPRESSION:1. CT head demonstrates subarachnoid and intraventricular bloodand signs of early
obstructive hydrocephalus
DISEASE
.2. CT angiography of the head demonstrates a 3.5 mm
aneurysm
DISEASE
from theanterior communicating artery at the junction of the right A1and A2 segment and pointing to the left side. No other
aneurysms
DISEASE
are seen in the head.3. CT angiography of the neck demonstrates no
vascular occlusion
DISEASE
or stenosis.CT Head [**2166-4-12**]:IMPRESSION:1. Status post coiling of
ACOM aneurysm
DISEASE
. Stable amount ofsubarachnoid
hemorrhage
DISEASE
with interval redistribution. Minimal intervalincrease in theleft lateral ventricle IVH.2. Diffuse sulcal effacement as before likely secondary tomild global
edema
DISEASE
.3. No new
hemorrhage
DISEASE
.ECHO [**2166-4-14**]:The left atrium is mildly dilated. No
atrial septal defect
DISEASE
isseen by 2D or color Doppler. Left ventricular wall thicknesscavity size and regional/global systolic function are normal(LVEF Admission Date: [**2149-11-5**] Discharge Date: [**2149-11-20**]Date of Birth: [**2076-10-17**] Sex: FService: SURGERY
Allergies
DISEASE
:Sulfa (Sulfonamides) / FlagylAttending:[**First Name3 (LF) 4111**]Chief Complaint:Mental declineAbnormal gaitSlurred SpeechMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:73F with programmable VP shunt for normal pressure
hydrocephalus
DISEASE
with noted decline in cognitive function since [**Holiday 1451**] toinclude episodes of left arm
weakness/numbness slurred
DISEASE
speechand altered vision/hearing.Past Medical History:
Crohn's disease
DISEASE
Breast cancer
DISEASE
(Admission Date: [**2191-8-22**] Discharge Date: [**2191-9-3**]Date of Birth: [**2123-11-18**] Sex: MService: CCU/[**Doctor Last Name 1181**]/MEDICINECHIEF COMPLAINT:
Cardiac arrest
DISEASE
and unresponsiveness.HISTORY OF PRESENT ILLNESS: The patient is a 67 year old manwith no cardiac history who had flu like symptoms for severaldays and was at [**Location (un) **] on [**2191-8-22**] to purchase overthe counter medicines. The staff there observed that heappeared sick. He had a
syncopal
DISEASE
episode and by-standersinitiated CPR. It is unclear how long he was down.When the EMTs arrived he was
asystolic
DISEASE
. He was intubatedand given Epinephrine. He was in
pulseless
DISEASE
electrical arrestwhich converted to sinus rhythm after five minutes. He wasbrought to [**Hospital3 **] where he was unresponsive and headCT was negative for
bleed
DISEASE
.He was transferred to [**Hospital1 69**][**2191-8-22**] for cardiac catheterization which showed cleancoronary arteries with ejection fraction of 41%Admission Date: [**2163-7-19**] Discharge Date: [**2163-7-23**]Date of Birth: [**2091-3-10**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:Codeine / PenicillinsAttending:[**First Name3 (LF) 1283**]Chief Complaint:
Dyspnea
DISEASE
on exertionMajor Surgical or Invasive Procedure:[**2163-7-19**] - Ministernotomy with
Primary ASD
DISEASE
closureHistory of Present Illness:This is a 72-year-old female who has
shortness of breath
DISEASE
onexertion. Her work-up revealed an atrioseptal defect of thesecundum type of left and right shunting and elevated rightheart pressures. It was recommended that she have this repaired.The risks were explained to her and she agreed to proceed withoperation to close her atrioseptal defect.Past Medical History:1.
HTN
DISEASE
2.
Hypothyroidism
DISEASE
3.
Atrial fibrillation
DISEASE
s/p ablation [**3-23**]4.
ASD secundum type
DISEASE
with left to right shunting on echoEcho [**12-3**] (TEE): nl LA size no thrombus mod dilated RAAdmission Date: [**2137-8-23**] Discharge Date: [**2137-8-27**]Date of Birth: [**2072-2-17**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Zestril / Statins-Hmg-Coa Reductase InhibitorsAttending:[**First Name3 (LF) 1505**]Chief Complaint:exertional
chest pain
DISEASE
Major Surgical or Invasive Procedure:[**2137-8-23**] Coronary artery bypass grafting x2 withleft internal mammary artery graft left anterior descendingreverse saphenous vein graft to the posterior descendingartery.History of Present Illness:65 year old male with exertional
chest pain
DISEASE
and positive stresstest recently found to have severe three vessel coronary arterydisease. He is scheduledfor surgical revascularization on [**2137-8-23**].Past Medical History:
Hypertension
DISEASE
Dyslipidemia
DISEASE
[**First Name8 (NamePattern2) **] [**2136-1-10**]Glucose Intolerance
Varicose Veins
DISEASE
Erectile Dysfunction
DISEASE
Right Shoulder Pain
DISEASE
History of
Bells Palsy
DISEASE
s/p
Vein
DISEASE
Stripping of Right GSVs/p Left Groin
Lipoma
DISEASE
s/p surgery radiation [**2105**]Social History:Occupation: Cook at hotelLives with: wife[**Name (NI) **]: AsianTobacco: quit 30 yrs agoAdmission Date: [**2122-5-30**] Discharge Date: [**2122-6-8**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 710**]Chief Complaint:Respiratory failure/sepsisMajor Surgical or Invasive Procedure:MICU stay [**2122-5-30**]-Admission Date: [**2172-2-12**] Discharge Date: [**2172-2-18**]Date of Birth: [**2088-9-22**] Sex: MService: MEDICINE
Allergies
DISEASE
:VancomycinAttending:[**First Name3 (LF) 3531**]Chief Complaint:
hypotension
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:This is an 83 y.o male with a history of MDS
HTN gout CVA
DISEASE
afib
CHF colon cancer
DISEASE
s/p colectomy with ostomy who initiallypresented to [**Location (un) 620**] with
weakness
DISEASE
and
chills
DISEASE
. There he wasfound to have an elevated WBC from baseline decreased plateletcounts and positive UA..In the emergency department his initial vitals were VS at [**Telephone/Fax (2) 4146**]00/63 18 98%. Here he was noted to have guaiacpositive brown stool from ostomy blood near stoma. During hisstay in the ED his SBP was running in 90's. He received atotal of 2L IVF. He was found to have questionable ischemic vs.emboli to the finger. Vascular surgery was consulted whobelieved this to be consistent with
bruising
DISEASE
no concern for
ischemia
DISEASE
. EKG shows STD laterally trop .05 he did not receivean aspirin. CXR unremarkable. The patient had 3 PIVs placed.He was given ceftaz and linezolid empirically as well as stressdose steroids..On arrival to the [**Hospital Unit Name 153**] the patient stated that his only concernwas
left shoulder pain
DISEASE
for a few days-inside the joint someradiation no
paresthesias
DISEASE
or weakness. Pt's aid reportedincreased
diarrhea
DISEASE
and output from the stoma that Admission Date: [**2172-3-5**] Discharge Date: [**2172-3-8**]Date of Birth: [**2088-9-22**] Sex: MService: MEDICINE
Allergies
DISEASE
:VancomycinAttending:[**First Name3 (LF) 1990**]Chief Complaint:Chief Complaint: Leg
pain
DISEASE
AMS
hypotension
DISEASE
leukocytosisMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:Mr. [**Known lastname 4148**] is a 83 year old male with a history of
MDS
DISEASE
CVAs
PVD CHF colon cancer
DISEASE
s/p iliostomy and recent
C. difficile
DISEASE
collitis
DISEASE
who presents with
left leg pain
DISEASE
and altered mentalstatus was found to be relatively
hypotensive
DISEASE
and have a
leukocytosis
DISEASE
..Mr. [**Known lastname 4148**] was recently admitted to [**Hospital1 18**] on [**2-21**] and treatedfor left leg
pain
DISEASE
. His furosemide dose was decreased on thatadmission and he began receiving weekly transfusions for hisend-stage
MDS
DISEASE
. Per his family his bilateral lower extremity hasprogressively worsened over the last couple of weeks and theredness in his left lower leg has worsened significantly in thelast two days. Per family the patient's PCP increased thepatient's lasix to 20 mg daily yesterday. Per family Mr.[**Known lastname 4148**] became unusually cantankerous the evening prior toadmission and this morning he was screaming at family asking tohave his legs taken off because of the
pain
DISEASE
. He seemed somewhatmore confused as well. Last night he also had night sweats and
chills
DISEASE
. It is unclear if he was
febrile
DISEASE
as a temperature was nottaken. He did not receive any of his morning medications thismorning and family brought him to the ED because of concern forthe leg
pain
DISEASE
and possible
sepsis
DISEASE
from his leg..In the ED initial vs were: BP 106/54 HR 72 R 30 O2 sat 86%.Patient was felt to globally appear unwell. Labs were notablefor a WBC count of 37.2 and lactate of 3.3. Chest x-ray was readas no acute process. Patient was given cefepime 2g IVlevofloxacin 750 mg IV 500 cc NS a six pack of platelets andmorphine 1 mg IV x 5. He was ordered for blood but did notreceive it prior to leaving the ED. Vital signs on transfer wereBP 91/55 HR 100 98% on
RA
DISEASE
RR 16..On the floor the patient states that he feels terrible but isunable to specify exactly why he feels so and initially deniedany
pain
DISEASE
anywhere (specifically
chest abdomen legs headache
DISEASE
).He denied any
shortness of breath or nausea
DISEASE
. He was unable tourinate but refused a catheter. Family states mental status isstill not normal but somewhat improved from earlier..Review of sytems: (per family and patient)(Admission Date: [**2134-8-12**] Discharge Date: [**2134-8-20**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1974**]Chief Complaint:
Dyspnea
DISEASE
Major Surgical or Invasive Procedure:IntubationHistory of Present Illness:82yo Russian speaking F with a PMH of
type II
DISEASE
DM
HTN
DISEASE
hyperlipidemia obesity pulmonary HTN
DISEASE
and
anemia
DISEASE
who presentedto the ED this AM with worsening SOB x 2 weeks. Per the EDresident the patient noted that she had had worsening SOB x 2weeks (documented as 2 days [**Name8 (MD) **] RN note) and also complained of
orthopnea
DISEASE
and increasing
lower extremity swelling
DISEASE
and
weeping
DISEASE
from a
venous stasis ulcer
DISEASE
on her L shin. The patient was ableto communicate this verbally to ER resident (RN notes she wasonly able to speak in 4 word sentences). Her VNA stated that shewas only 94% on 2L O2 at home and had rales [**12-28**] way upbilaterally. On initial assessment in the [**Hospital1 18**] ER her vitalsigns were T 98.2 BP 167/60 HR 61 RR 23 sats 100% on
RA
DISEASE
. Onnext assessment (2 hrs later) pt was felt to be very SOB whileattempting to use the bed pan. RN noted her to be duskydiaphoretic. HR 72 RR 28 sats 90% on
RA
DISEASE
. She was placed on a
NRB
DISEASE
with improvement in her O2 sats to 98%. BP rose to 210/74then 215/93. CXR was taken and read as c/w
pneumonia
DISEASE
. Blood cxwere obtained and ceftriaxone was
administtered
DISEASE
. 90 mins latershe was felt to be diaphoretic again with increased work ofbreathing. Her O2 sats dropped to 90% by
NRB
DISEASE
and she was preppedfor intubation. She was given 2mg versed and was intubated. SBP210 -Admission Date: [**2159-10-24**] Discharge Date: [**2159-11-10**]Date of Birth: [**2090-1-18**] Sex: FService: MEDICINE
Allergies
DISEASE
:Losartan / Aspirin / Lisinopril-HctzAttending:[**First Name3 (LF) 4153**]Chief Complaint:
pain
DISEASE
in left shoulderMajor Surgical or Invasive Procedure:left shoulder hemiarthroplasty [**2159-10-24**]History of Present Illness:69 yo somalian woman with 6week old left hyumerous fx intialpresented 4weeks out from presumed injury while being transferedto stretcher for dialysis came in to [**Hospital1 **] mc for shunt evalfistogram showed left humerous fx because of left arm shunt dr[**Last Name (STitle) **] felt that the only way could fix the humerous wouldjepodize the shunt the patiebt who need the hemodaylisas accessswitch to the rt sidePast Medical History:1. Type 2
diabetes
DISEASE
2.
Diabetic nephropathy
DISEASE
3. Status post left femur
fracture
DISEASE
4.
Hyponatremia
DISEASE
5.
Hypercholesterolemia
DISEASE
6. Unsteady gait7.
Cataracts
DISEASE
8. Back
pain
DISEASE
9.
Hypertension
DISEASE
10.
Anemia
DISEASE
of
chronic disease
DISEASE
Social History:Lives with son who is very involved and well informed regardingher care needs. Non smoker. No EtOHFamily History:NoncontributoryPhysical Exam:heent wnlchest exp rhochi decresaed bs[**Last Name (un) **] rrr no mrgabd sft nt ndext left arm swollen eccchymotic pain ful romneuro intactPertinent Results:[**2159-10-24**] 03:12PM BLOOD WBC-12.1*# RBC-3.72* Hgb-10.5* Hct-33.6*MCV-90 MCH-28.1 MCHC-31.1 RDW-20.7* Plt Ct-267[**2159-10-24**] 03:12PM BLOOD Plt Ct-267[**2159-10-24**] 03:12PM BLOOD Glucose-160* UreaN-29* Creat-3.7* Na-141K-3.2* Cl-98 HCO3-30 AnGap-16[**2159-10-24**] 01:20PM BLOOD Type-ART FiO2-50 pO2-212* pCO2-37pH-7.58* calHCO3-36* Base XS-12 Intubat-INTUBATEDVent-CONTROLLED[**2159-10-24**] 02:51PM BLOOD Glucose-237* Lactate-2.7* Na-136 K-3.3*Cl-99*[**2159-10-24**] 01:20PM BLOOD Glucose-193* Lactate-1.5 Na-138 K-3.4*Operative report ([**2159-10-24**]):Service: ORT Date: [**2159-10-24**]Date of Birth: [**2090-1-18**] Sex: FSurgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **] [**MD Number(1) 4158**]PREOPERATIVE DIAGNOSIS: Left
proximal humerus fracture
DISEASE
.POSTOPERATIVE DIAGNOSIS: Left proximal humerus fracture.PROCEDURE: Left
proximal humerus hemiarthroplasty
DISEASE
.INDICATIONS: Mrs. [**Known firstname 4159**] [**Known lastname 4160**] is a 69-year-old female patientwith a complex medical history including end-stage renaldisease on dialysis
diabetes
DISEASE
. She fell approximately 4 to 6weeks ago sustaining a two-part proximal humerus
fracture
DISEASE
that has not healed. Over the last 2 weeks of her medicaladmission to manage respiratory issues it was noted that theflow from her
arterial venous fistula
DISEASE
which is on the injuredside of her extremity was deficient. An angiogram wasobtained which demonstrated the presence of the humerus
fracture
DISEASE
. It is unclear when this
fracture
DISEASE
occurredpresumably it could have occurred during transportation giventhat the patient has no history of falling. The
fracture
DISEASE
wassignificantly displaced andsignificantly angulated. The patient received alternativehemodialysis access and the left upper extremity fistula wasleft at this point unused in preparation for possible surgeryto address the humerus
fracture
DISEASE
. the patient has so far not develop any healingor callus on films. I think this is not unusual given hermedicalhistory andbelieve a repair of this 2-part humerus
fracture
DISEASE
wouldprobably result in a non [**Hospital1 **] and I therefore believe that theapproach to address her
fracture
DISEASE
instability surgically is toperform a hemiarthroplasty. The family agrees and she nowpresents for procedure.PROCEDURE IN DETAIL: The patient was brought to theoperating room and after the successful induction of generalanesthesia was placed in the beach-chair position. The leftupper extremity was prepped and draped in the usual sterilemanner. Via the deltopectoral approach the
fracture
DISEASE
wasexposed. There was significant soft tissue scarring but nocallous and there was good lateralperfusion on the soft tissues which
bleed
DISEASE
considerably. Thisis secondary to the presence of the
fistula
DISEASE
nearby.Hemostasis was achieved with [**Last Name (un) 4161**] electrocautery. Thedeltopectoral interval was found and the
fracture
DISEASE
wasexposed. The humeral head lesser tuberosity and greatertuberosity were osteotomized and preserved and the remaininghead was removed. The canal was exposed and reamed andbroached to accept a 12 mm Osteonics humeral prosthesis. A 21mm humeral head was then selected and was found to giveappropriate fit and range of motion. At this point the canalwas irrigated. The final components were then brought to thefield and cemented with one bag of PMMA cement. The finalcomponents were assembled and the lesser tuberosity andgreater tuberosity were repaired over the prosthesis usingthe threaded holes in the prosthesis. The wound wascopiously irrigated and closed in layers with 0 PDS and 2-0nylon over a drain. Dr. [**Last Name (STitle) 1005**] was present for the entireprocedure. All counts of sponges and instruments werecorrect. C arm imaging was used at the end of the procedure toestablish the appropriate height and anatomy was restored.The patient tolerated the procedure well and was taken torecovery room without incident. Dr. [**Last Name (STitle) 1005**] was present forthe entire procedure.CT head ([**11-2**]):FINDINGS: There is no acute intra- or
extra-axial hemorrhage
DISEASE
orshift of normally midline structures. The ventricles cisternsand sulci are somewhat prominent likely due to atrophicchanges. Again identified are scattered hypodensities within thesubcortical white matter consistent with small vessel ischemicdisease. A small area of decreased attenuation is identifiedwithin the right basal ganglia consistent with prior lacunar
infarction
DISEASE
unchanged from prior studies. The [**Doctor Last Name 352**]-white matterdifferentiation appears preserved. There has been intervalopacification of the mastoid air cells bilaterally. There isminimal thickening of the right maxillary sinus. The visualizedsoft tissues appear unremarkable.IMPRESSION: No
acute hemorrhage
DISEASE
. Evidence of chronic small
vessel ischemic disease
DISEASE
as well as prior lacunar
infarcts
DISEASE
unchanged.[**11-8**] CT abd/pelvis69 year old woman with diffuse persistent
abdominal pain
DISEASE
s/p
PEA arrest
DISEASE
elevated lactateREASON FOR THIS EXAMINATION:Please evaluate for
mesenteric ischemia
DISEASE
- angiogram protocolCONTRAINDICATIONS for IV CONTRAST: None.INDICATION: Diffuse persistent
abdominal pain
DISEASE
status post PEAarrest with elevated lactate. Concern for
mesenteric ischemia
DISEASE
.CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Tiny (2 mm)nodule seen within the left lower lobe not clearly visualizedat the time of the previous CT examinations. The visualizedportions of the heart and pericardium appear unremarkable. Theliver spleen and adrenal glands appear unremarkable.Gallbladder contains a calcified stone in layering calciumconsistent with milk of calcium. There is stranding about theinferior aspect of the pancreas within the mesenteric root. Theaorta is normal in caliber with
mural calcifications
DISEASE
consistentwith
atheromatous disease
DISEASE
. The kidneys appear atrophicbilaterally. The large and small bowel loops are normal incaliber. There is mucosal thickening within a short segment ofcecum. No other areas of
abnormal bowel wall thickening
DISEASE
areidentified. There is no free intraperitoneal air and no freefluid within the abdomen. There is no pathologic appearingmesenteric or retroperitoneal lymphadenopathy.CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: The bladderdistal ureters rectum and sigmoid colon appear unremarkable.There are
uterine calcifications
DISEASE
. The
uterus and adnexa
DISEASE
appearotherwise unremarkable. There is no pathologic appearing pelvicor
inguinal lymphadenopathy
DISEASE
. There is diffuse stranding withinthe subcutaneous tissues of the left buttock and right buttockto a slightly less prominent degree. Multiple
calcifications
DISEASE
areseen within the soft tissues of the buttocks consistent withinjection
granulomas
DISEASE
.BONE WINDOWS: Bone windows demonstrate unusual contour of theleft femoral neck with
bowing
DISEASE
and heterogeneous lucency withinthe femoral neck and greater trochanter. No suspicious lytic orsclerotic osseous lesions are identified.MULTIPLANAR REFORMATS: Coronal and sagittal reformationsdemonstrate a short segment of mucosal thickening within thececum.IMPRESSION:1. Short segment of mucosal thickening within the cecum findingof uncertain significance. The differential diagnoses include
infectious inflammatory
DISEASE
or
ischemic colitis
DISEASE
.2. Peripancreatic stranding finding that could indicate
pancreatitis
DISEASE
. Clinical correlation is recommended.3. Small bilateral
pleural effusions
DISEASE
and
bibasilar atelectasis
DISEASE
.2 mm left lower lobe pulmonary nodule. If there is no history ofprior
malignancy
DISEASE
this may be further evaluated by follow-up CTin 1 year.4.
Cholelithiasis
DISEASE
and milk of calcium within the gallbladder.5. Unusual configuration of the left femoral neck finding thatcould suggest etiology such as
fibrous dysplasia
DISEASE
Brief Hospital Course:ORTHOPEDIC SURGERY:on [**2159-10-24**] she was admitted to the sda area anesthesia saw herand had cocerns about her respiratory status and had a cxr doneit showed no pna and shecwas taken to the or and underwent aleft shoulder hemiarthroplasty transfered to pacu stable* * * * * * * * * * * * * * * * * * * *MEDICINE:Patient was transferred to medicine on [**2159-10-26**]. The plan atthat time was for patient to recive hemodialysis and todischarged home. While in hemodialysis patient became
hypotensive
DISEASE
. House officer was called. While attempting to getan ABG patient had
respiratory arrest
DISEASE
and a code blue wasactivated. Patient was found to have
pulseless
DISEASE
electricalactivity. Patient was successfully resuscitated and transferredto the MICU. CTA was positive for
pulmonary embolism
DISEASE
andpatient was started on Heparin. Her EKG had ST and STdepressions laterally and Echocardiogram showed no evidence ofright heart strain. Her blood pressure stabilized and she wastransferred back to the floor on [**2159-10-29**]. The remainder of herhospital course was characterized by persistent intermittentepisodes of
hypotension
DISEASE
down to the 80's systolic. Measuringblood pressure on Ms. [**Known lastname 4160**] is problem[**Name (NI) 115**] as she has a healingsurgical wound on her left arm and her right has poorvasculature presumably from multiple past lines. She wasregularly
hypotensive
DISEASE
(SBP 80's) during hemodialysis. Her bloodpressure responded well to 250 cc normal saline boluses.Of note during this admission patient had one episode ofunresponsiveness. Patient was treated with
narcan
DISEASE
with slightimprovement and aggressive electrolyte repletion (phosphate andmagnesium).) Vital signs were at her baseline throughout. Noacute changes on CXR or ECG. FSBG normal. Head CT negative.She returned to baseline over the course of [**2-22**] hours and theepisode was attributed to excessive
pain
DISEASE
medications andmultiple electrolyte abnormalities. The remainder of herhospital course is organized by problem below:.#Anticoagulation: patient transitioned from heparin to coumadinwithout incident. Still attempting to titrate to maintain INRbetween [**2-22**]. Her INR on the date of discharge wassupratherapeutic. Her coumadin should be held on [**11-10**] andre-started on [**11-11**] at 1 mg qhs IF her INR comes down totherapeutic range (goal [**2-22**])..#. Humeral
Fracture
DISEASE
: Films were reviewed by orthopedic surgery.No
fracture
DISEASE
or damage to hardware during CPR evident on plainfilm on [**2159-10-29**]. She will need follow up with orthopedics forremoval of stitches..#
Blood loss
DISEASE
- On two occaisions patient's hematocrit drifteddown. Neither could be entirely accounted for by surgery (perortho there was minimal
blood loss
DISEASE
Admission Date: [**2159-12-5**] Discharge Date: [**2159-12-20**]Date of Birth: [**2090-1-18**] Sex: FService: MEDICINE
Allergies
DISEASE
:Losartan / Aspirin / Lisinopril-HctzAttending:[**First Name3 (LF) 4162**]Chief Complaint:
fever
DISEASE
Major Surgical or Invasive Procedure:Intubation for airway protectiontunneled line change over wire [**2159-12-18**]History of Present Illness:69 y/o female wtih PMH significant for
ESRD
DISEASE
on HD type 2 DMand recent PE resulting in
PEA arrest
DISEASE
admitted through the EDwith
sepsis
DISEASE
of unknown etiology. Pt was recently admitted to[**Hospital1 18**] from [**11-16**] thorugh [**11-23**] with
hypotension
DISEASE
thought to besecondary to overdiuresis at HD. However a
septic
DISEASE
component tothe
hypotension
DISEASE
was also considered as the pt was found to havecitrobacter in her urine and C diff in her stool. Pt was thendischarged to [**Hospital1 100**] Senior Life where she was in her normalstate of health until three days ago. Her son reports that shethen developed a
headache
DISEASE
and
fevers
DISEASE
started three days agowhich were treated with tylenol. Then this morning shedeveloped
fatigue
DISEASE
and did not eat well. He son also notes thatshe appeared to be working hard to breath. She was found to be
febrile
DISEASE
to 101.9 and received levoflox and vancomycin. Pt wasthen sent to the [**Hospital1 18**] ED for further evaluation. Per notes ptdenied SOB CP and
abdominal pain
DISEASE
prior to intubation. She didcomplain of a left frontal headache..In the ED the pt's VS were singificant for a
fever
DISEASE
of 103.8
tachycardia
DISEASE
in the 130s-150s and initial
hypertensive
DISEASE
in the140s. Her oxygen saturation was 96% on
RA
DISEASE
but she was tachypneicto 31. She was obtunded and was thus intubated for airwayprotection. Post-intubation the pt's BP acutely dropped to58/19 in the setting of propofol. When this medication wasdiscontinued her BP came back up to the 70s-90s/30s-50s. Pt wasthen initiated on the
sepsis
DISEASE
protocol. In the ED she receivedvancomycin levofloxacin flagyl and cefepime (2 gm). Shereceived a total of 4 liters of NS then was started on levophedfor continued
hypotension
DISEASE
. Pt is now transferred to the [**Hospital Unit Name 153**] forfurther care..Per pt's son she is bedbound at baseline due to her multiple LEfemur
fractures
DISEASE
.Past Medical History:1. Type 2
diabetes mellitus
DISEASE
2.
Diabetic nephropathy
DISEASE
resulting in
ESRD
DISEASE
for which she is onHD. Pt was due for
HD
DISEASE
but missed it secondary to her illness.She normally receives
HD
DISEASE
on Mon Wed and Fri.3. Status post left femur
fracture
DISEASE
4.
Hyponatremia
DISEASE
5.
Hypercholesterolemia
DISEASE
6. Unsteady gait7.
Cataracts
DISEASE
8. Back
pain
DISEASE
9.
Hypertension
DISEASE
10.Anemia of
chronic disease
DISEASE
11. S/P L shoulder hemiarthroplasty following a left humeralfracuture in [**10/2159**]- [**Last Name (un) 4163**] was complicated by a
PEA arrest
DISEASE
secondary to PE.12. PE [**2159-10-27**] leading to
PEA arrest
DISEASE
Social History:Lives with son who is very involved and well informed regardingher care needs. Non smoker. No EtOHFamily History:NoncontributoryPhysical Exam:94.5 132/50 108 15 100%AC 500/15/.50/PEEP 5Gen- Sedated and intubated. Grimaces eyes when they are opened.HEENT- NC AT. Right pupil ERRL. Surgical left pupil. Anictericsclera. MMM.Cardiac- RRR. S1 S2. No mrg.Pulm- CTA anteriorlly.Abdomen- Obese. Soft. NT. ND. Positive bowel sounds.Extremities- Feet mildly cool. 2Admission Date: [**2159-12-29**] Discharge Date: [**2160-1-6**]Date of Birth: [**2090-1-18**] Sex: FService: MEDICINE
Allergies
DISEASE
:Losartan / Aspirin / Lisinopril-HctzAttending:[**First Name3 (LF) 398**]Chief Complaint:
fever hypotension
DISEASE
Major Surgical or Invasive Procedure:trans-esophageal echocardiogramHistory of Present Illness:69F with h/o
ESRD
DISEASE
on HD PE (PEA arrest) recent admit for
sepsis
DISEASE
of unclear etiology from [**Date range (2) 4167**] presenting toED with
fever
DISEASE
Tm 102
hypotension
DISEASE
decreased appetite and
lethargy
DISEASE
per son. Pt has had loose stools x 2 in the past fewdays with
hypomagnesemia
DISEASE
and
hypophosphatemia
DISEASE
receiving POrepletion w/o benefit. Pt received empiric Abx coverage ofVanc/Cefepime/Levaquin/Flagyl at [**Hospital **] Rehab prior to transfer..Recent hospitalization notable for intubation for airwayprotection in setting of
obtundation
DISEASE
no clear source of
infection
DISEASE
. Micro data remarkable for yeast and
VRE
DISEASE
in urine forwhich pt received 7d Fluconazole and 14d course of Linezolid (LD[**2159-12-27**]). Pt intermittently on Flagly Cefepime until culturedata remained negative. Also failed [**Last Name (un) **] stim and was on stressdosed steroids. No evidence of
infection
DISEASE
in sputum blood orCSF. CT Abd/Pel unremarkable. PICC removed and tunneled HDcatheter changed over wire on [**2159-12-18**] (from [**10-15**]). A new PICCwas inserted prior to discharge on [**12-18**]..In ED Tm 102 tachy 110-120 BP dropped to 82/17 intermittentlythen improved to normal tachypneic 22-28 99%
RA
DISEASE
. Received Gentx 1 Fluconazole 400mg IV x1. ROS: denies any
pain
DISEASE
orlocalizable symptoms at this time. Per sons' report ptAdmission Date: [**2160-1-8**] Discharge Date: [**2160-1-16**]Date of Birth: [**2090-1-18**] Sex: FService: MEDICINE
Allergies
DISEASE
:Losartan / Aspirin / Lisinopril-HctzAttending:[**First Name3 (LF) 4162**]Chief Complaint:
fever hypotension
DISEASE
Major Surgical or Invasive Procedure:Hemodialysis MWFHistory of Present Illness:Pt is a 69 y/o female with
ESRD
DISEASE
bed bound humeral and femoral
fracture
DISEASE
who was recently admitted to ICU with enterobacter/klebsiella/Pseudomonas
UTI
DISEASE
and
bacteremia
DISEASE
on Gent Cefepime viaPICC who was admitted with increased change in mental statusless responsive and
fever
DISEASE
x 1 day. Patient got
HD
DISEASE
on [**2160-1-7**]and when she came to the ED on [**1-8**] her SBP was found to be inthe 80s. Patient got 1.5L NS and BP returned to SBP 120s. Herlactate was 1.0.
ID
DISEASE
and renal consulted and
ID
DISEASE
recommendedcontinuing patient on meropenum linezolid and Gentamycin.Patient got vancomycin in ED..History obtained from son on Transfer he states that pt wasdischarged on saturday sunday she felt weak and was somnolent.After dialysis on monday she became more lethargic andunresponsive and was transferred to [**Hospital1 18**] ED. She gotAdmission Date: [**2160-1-18**] Discharge Date: [**2160-3-5**]Date of Birth: [**2090-1-18**] Sex: FService: MEDICINE
Allergies
DISEASE
:Losartan / Aspirin / Lisinopril-HctzAttending:[**First Name3 (LF) 4162**]Chief Complaint:aspiration
hypoxia
DISEASE
Major Surgical or Invasive Procedure:Multiple intubationsNasogastric tubeLeft internal jugular central linePEG tube placed and replacedHistory of Present Illness:This is a 69 year old bedbound Somalian speaking only woman wellknown to [**Hospital1 18**] with
end stage renal disease
DISEASE
on hemodialysis
diabetes mellitus
DISEASE
type 2 chronic
hyponatremia
DISEASE
history of
pulmonary embolus
DISEASE
on coumadin and recent admissions to ICU withenterobacter/klebsiella/pseudomonas
bacteremia
DISEASE
who presents fromrehab with
hypoxia
DISEASE
and decreased responsiveness in setting ofapparent aspiration. Events at rehab unclear but duringhemodialysis patient desatted to 74%. Apparently a code wascalled but event details not known. Pt was suctioned whichproduced Admission Date: [**2173-9-13**] Discharge Date: [**2173-9-17**]Date of Birth: [**2103-10-30**] Sex: MService: OTOLARYNGOLOGY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4181**]Chief Complaint:
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:1. Emergent cricothyrotomy with subsequent closure.2. Tracheotomy with a #7 Portex tracheotomy tube.History of Present Illness:69-year-old patient with a history of T1 N0 squamous cell
carcinoma of the left true vocal cord
DISEASE
who presented to the EDwith
respiratory distress
DISEASE
. Patient is currently under the careofDr. [**First Name (STitle) 3311**] at [**Hospital1 112**] and has been treated with external beamirradiation ending in [**Month (only) 216**]. Recently he has apparently beentreated for fungal mucusitis.In the ED the patient was stridorous and was treated withheliox. Accessory muscle use were required for breathing. Withtreatment the patient significantly improved. After aconversation with Drs. [**First Name (STitle) 3311**] and [**Name5 (PTitle) **] the decision wasmade to go to OR for a tracheotomy to secure the airway.The plan was to bring the patient to the OR for this reason.Past Medical History:1.
Squamous cell carcinoma
DISEASE
as stated in history of presentillness.2. Benign
prostate hypertrophy
DISEASE
.3.
Diabetes mellitus
DISEASE
.4. Gallbladder removal.5.
coronary artery disease
DISEASE
6. perirectal abscess in [**2156**]7.
osteoarthritis
DISEASE
Social History: Mr. [**Known lastname 4182**] [**Last Name (Titles) 4183**] from [**Country 532**] in [**2155**]. Heworked as a construction engineer. He is married and lives withhis wife [**Street Address(1) 4184**]. They have one daughter who lives inthe area. The patient smoked one pack per day of unfilteredcigarettes for 50 years.Family History:NCPhysical Exam:Breathing well on helioxNo
neck adenopathy
DISEASE
no neck massesEOMIFiberoptic exam:No
supraglottic edema
DISEASE
left true cords minimally mobileexudatesover cords c/w possible
fungal infection
DISEASE
. Posterior glottic gap4-5 mm.Face symmetricPertinent Results:[**2173-9-13**] 10:12PM CK-MB-7 cTropnT-Admission Date: [**2196-6-26**] Discharge Date: [**2196-7-4**]Date of Birth: [**2137-10-7**] Sex: FService: [**Doctor Last Name 1181**]HISTORY OF PRESENT ILLNESS: This is a 59-year-old womanwith multiple medical problems including coronary arterydisease status post coronary artery bypass graft chronic
obstructive pulmonary disease
DISEASE
on home oxygen
insulin-dependent diabetes mellitus
DISEASE
peripheral vasculardisease status post above the knee amputation bilateralcarotid endarterectomies femoral-popliteal bypass whopresented on [**6-26**] with
shortness of breath
DISEASE
after beingfound by her daughter obtunded and
cyanotic
DISEASE
with the oxygennasal cannula removed. The patient presented to theEmergency Room on [**6-26**] with
shortness of breath
DISEASE
progressive over the course of the preceding days. Herdaughter reported finding the patient
cyanotic
DISEASE
and obtundedlying in bed with her oxygen nasal cannula removed from herface. The patient also reported progressively increasing
swelling
DISEASE
of her extremities in the days preceding admission.On arrival to the Emergency Department the patient was 98%on 3 liters nasal cannula. She denied any
chest pain cough
DISEASE
fever
DISEASE
or
chills
DISEASE
.According to the patient she had been admitted to [**Hospital 4199**]Hospital several times between [**Month (only) 958**] and [**2196-4-22**] for
volume overload
DISEASE
and
chronic obstructive pulmonary disease
DISEASE
exacerbations. Per patient she was admitted in [**Month (only) 958**] forthree months and required three visits to the MedicalIntensive Care Unit with multiple intubations. She wasdischarged from [**Last Name (un) 4199**] in [**Month (only) **] and she had just completedher steroid taper that was initiated with these
flares
DISEASE
. Shewas then readmitted to [**Last Name (un) 4199**] on [**2196-6-10**] with
nausea
DISEASE
vomiting
DISEASE
and
lethargy
DISEASE
and was found on admission to be
febrile
DISEASE
with a potassium of 6.8 a blood sugar of 460 andelevated transaminases. At this time the
hyperkalemia
DISEASE
wasthought secondary to Zestril which was discontinued. Shewas treated with insulin and Kayexalate and discharged tohome on [**2196-6-22**].PAST MEDICAL HISTORY:1. Insulin-dependent
diabetes mellitus
DISEASE
2. Chronic
obstructive pulmonary disease
DISEASE
(dependent on homeoxygen uses steroids during
flares
DISEASE
history of multipleintubations)3. Coronary
artery disease
DISEASE
status post coronary arterybypass graft in [**2189**]4. Peripheral
vascular disease
DISEASE
status post femoral-poplitealbypass right above the knee amputation bilateral carotidendarterectomies5. Status post
abdominal aortic aneurysm
DISEASE
repair6.
Bipolar disorder
DISEASE
ALLERGIES: Sulfa TolinaseSOCIAL HISTORY: The patient lives alone in [**Hospital3 **].Her daughter lives in the area and helps to care for her.Her daughter has offered to have the patient move in withher but the patient has been reluctant to do so for fear ofbecoming a burden to her daughter. The patient admits tomultiple suicide attempts with pills in the last few yearsmost recently a few months ago. The patient also reportssevere
depression
DISEASE
following the
death
DISEASE
of her husband from[**Name (NI) 2481**] disease last year. The patient also expressesextreme frustration with the intensive medical care which shehas had to receive over the course of the last few years.PHYSICAL EXAMINATION: On admission to the EmergencyDepartment the patient had a temperature of 97.7 pulse of70 blood pressure 105/54 respiratory rate 14 and oxygensaturation of 98% on 3 liters by nasal cannula. In generalshe was comfortable breathing rapidly in no acute distress.Head eyes ears nose and throat examination showed thepatient to have severe
facial edema
DISEASE
and her extraocularmuscles were intact pupils equal round and reactive tolight. On neck examination there was no jugular venousdistention and no
carotid bruits
DISEASE
. On lung examination shehad decreased air movement in both lung fields but no
wheezes or rales
DISEASE
. On heart examination she had distantheart sounds a regular rate and rhythm with a
II/VI
systolic murmur
DISEASE
loudest at the right upper sternal borderwith no gallops. On abdominal examination she had normal
active bowel sounds
DISEASE
. Her abdomen was soft nondistended andnontender. There was no
hepatosplenomegaly
DISEASE
and no guardingor rebound. On extremity examination her right leg (statuspost above the knee amputation) there was pitting
edema
DISEASE
inthe thigh. In her left leg there was pitting
edema
DISEASE
to thethigh. On neurological examination she was alert andoriented x 3 extraocular muscles were intact pupils equalround and reactive to light moved three extremities 2Admission Date: [**2203-10-4**] Discharge Date: [**2203-10-26**]Date of Birth: [**2143-10-4**] Sex: MService: NEUROSURGERY
Allergies
DISEASE
:Codeine / Streptokinase / Iodine / Bee Pollens / NarcanAttending:[**First Name3 (LF) 78**]Chief Complaint:Admission Date: [**2203-11-19**] Discharge Date: [**2203-12-16**]Date of Birth: [**2143-10-4**] Sex: MService: NEUROSURGERY
Allergies
DISEASE
:Codeine / Streptokinase / Iodine / Bee Pollens / NarcanAttending:[**First Name3 (LF) 78**]Chief Complaint:Altered mental statusMajor Surgical or Invasive Procedure:VP shunt removal [**2203-11-20**]VP shunt placement [**12-6**]removal of Kwires R arm [**11-22**]History of Present Illness:Mr. [**Known lastname 3989**] is a 60y/o gentleman with
HTN
DISEASE
HLD CAD s/p MI
AFib
DISEASE
TIA colon cancer
DISEASE
s/p resection s/p
abdominal trauma
DISEASE
withsplenectomy and left hand digit amputations right forearm
fracture
DISEASE
with plan for hardware removal [**11-22**] as well ascomplicated hospital course last month for spontaneous
SAH
DISEASE
and
pneumonia
DISEASE
now s/p trach/PEG/VP shunt who was sent from rehab toan OSH for altered mental status and was transferred to [**Hospital1 18**]due to concern for VP shunt complication vs
infection
DISEASE
.He was admitted to Neurosurgery [**Date range (1) 4216**] after presenting to anOSH with the Admission Date: [**2161-9-22**] Discharge Date: [**2161-10-1**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4232**]Chief Complaint:
Hypothermia
DISEASE
at DilaysisMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:The patient is a 84 y.o. female with h/o
ESRD
DISEASE
on
HD
DISEASE
recentadmission for C diff
colitis
DISEASE
in [**2161-8-6**] a resident at[**First Name4 (NamePattern1) 4233**] [**Last Name (NamePattern1) **] admitted [**2161-9-22**] after she was found to behypothermic during HD yesterday. The patient with recent stoolpositive for cdiff at nursing home (C.Diff Admission Date: [**2172-3-5**] Discharge Date: [**2172-3-8**]Date of Birth: [**2109-10-8**] Sex: FService: NEUROSURGERY
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 1835**]Chief Complaint:
Meningioma
DISEASE
Major Surgical or Invasive Procedure:Right CraniotomyHistory of Present Illness:[**Known firstname 622**] [**Known lastname 1836**] is a 62-year-old woman with longstandinghistory of
rheumatoid arthritis
DISEASE
probable
Sweet's syndrome
DISEASE
andmultiple joint complications requiring orthopedic interventions.She was found to hve a right cavernous sinus and nasopharyngealmass. She underwent a biopsy of hte nasopharyngeal mass by Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] and the pathology including flowcytometrywas reactive for
T-cell lymphoid hyperplasia
DISEASE
only.She has a longstanding history of
rheumatoid arthritis
DISEASE
thatinvolved small and large joints in her body. Her disease iscurrently controlled by abatacept hydroxychloroquine andmethotrexate. She also has a remote history of erythematousnodules at her shins dermatosis (probable
Sweet's disease
DISEASE
)severe
holocranial headache
DISEASE
with an intensity of [**9-28**] anddysphagia. But her symptoms resolved with treatment for
autoimmune disease
DISEASE
. Please refer additional past medicalhistory past surgical history facial history and socialhistory to the initial note on [**2171-11-4**].She cam to the BTC for discussion about management of her rightcavernous sinus mass that extends into the middle cranial fossa.She had a recent head CT at the [**Hospital1 756**] and Woman's Hospital on[**2171-11-29**] when she went for a consultation there.She is neurologically stable without
headache nausea vomiting
DISEASE
seizure
DISEASE
imbalance or fall. She has no new systemic complaints.Her neurological problem started [**9-/2171**] when she experiencedfrontal pressure-like sensations. There was no temporalpatternAdmission Date: [**2136-4-4**] Discharge Date: [**2136-4-9**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 30**]Chief Complaint:
fatigue
DISEASE
Major Surgical or Invasive Procedure:R IJ placementHistory of Present Illness:This is a 84 year-old Russian speaking female with a history ofsystemic
hypertension
DISEASE
pulmonary arterial
hypertension
DISEASE
chronicdiastolic
CHF
DISEASE
who presents with
hypotension
DISEASE
drop in hematocritand guaiac positive stools. She reportedly collapsed 3 timestoday. Per son patient felt lightheaded every time she stoodup and had to sit back down to the floor. She has never had aproblem like this in the past. Denies any NSAID or alcohol use.
Denies hematemesis
DISEASE
. Occasional blood-tinged stool when shestrains but denies
hematochezia
DISEASE
. Denies any
fevers
DISEASE
. Deniesblack or bloody stools but stool always black because of iron.Of note patient was recently admitted and discharged on[**2136-4-2**] with multifocal
pneumonia
DISEASE
.In the ED initial vitals were T:98.3 BP:81/20 HR:79 O2 Sat100% on 4L. NG lavage was negative. Patient received 2 unitsPRBC and right IJ placed for persistent
hypotension
DISEASE
..ROS: The patient denies any
fevers chills
DISEASE
weight change
nausea vomiting diarrhea constipation chest pain orthopnea
DISEASE
PND lower extremity oedema cough urinary frequency urgency
dysuria lightheadedness gait unsteadiness focal weakness
DISEASE
vision changes
headache rash
DISEASE
or skin changes.Past Medical History:#.
Pulmonary HTN
DISEASE
on 2 litres home O2#.
CHF
DISEASE
- last echo [**8-1**]: ef Admission Date: [**2161-11-21**] Discharge Date: [**2161-12-16**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 330**]Chief Complaint:
Shortness of breath
DISEASE
Major Surgical or Invasive Procedure:TracheostomyCentral Line PlacementHistory of Present Illness:This is a 84 y/o with h/o
ESRD
DISEASE
A fib who comes to theEmergency Department after being found on HD with increasing
shortness of breath
DISEASE
. Patient found to be 10L positive but theywere unable to take enough fluid off so they took off 2L.Patient describes that over the last few weeks she has beenfeeling a little more short of breath. She reports one Admission Date: [**2190-3-27**] Discharge Date: [**2190-3-28**]Date of Birth: [**2157-12-22**] Sex: FService: NEUROLOGY
Allergies
DISEASE
:Penicillins / AspirinAttending:[**First Name3 (LF) 618**]Chief Complaint:
syncopal
DISEASE
episodeMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:[**Known firstname 4252**] is a 32 year old right handed woman with a historyof
hypertension
DISEASE
(post partum only)
migraine headaches
DISEASE
and
G6PD
DISEASE
deficiency who presents to the [**Hospital1 18**] ED as a transfer from the[**Hospital Ward Name **] where she was noted to have a
syncopal
DISEASE
episode whenwaiting to get a scheduled lumbar spine MRI due to complaints oflower back
pain
DISEASE
localized to the region of her epidural (presentonly since pregnancy).She is somnolent at the time of this history but states thatshewas given a prescription for some medicine to be taken prior tothe procedure. She took 4 pills and refers to a bottle oflorazepam 1mg tablets. Witnesses (per ED staff) state that shelost consciousness but did not have any evidence of
seizure
DISEASE
activity. Her vital signs at that time were notable for a bloodpressure of 180/110. She was noted to be oriented but lethargicand was sent to the ED for further evaluation.Upon arrival to the ED she had a CT of her head that wasnegative for any abnormality. The patient herself states thatshewas on
pain
DISEASE
medication (tylenol #3 and percocet for her back
pain
DISEASE
but discontinued this due to the fact that the medicationwas making both her and her baby constipateAdmission Date: [**2103-3-5**] Discharge Date: [**2103-3-11**]Service: MEDICINE
Allergies
DISEASE
:AugmentinAttending:[**First Name3 (LF) 2297**]Chief Complaint:Mixed
respiratory failure
DISEASE
Major Surgical or Invasive Procedure:IntubationCVLHistory of Present Illness:Mrs. [**Known lastname **] is an 87 year old female with a PMH significantfor
HTN asthma
DISEASE
and chronic mixed
respiratory failure
DISEASE
followedby Dr. [**Last Name (STitle) **] now admitted for
hypoxemic respiratory failure
DISEASE
. Thepatient was found by her family this morning in her bedroomconfused after possibly falling. At that time she wasdisoriented and looked short of breath with a Admission Date: [**2144-12-2**] Discharge Date: [**2144-12-16**]Date of Birth: [**2103-3-23**] Sex: FService: MEDICINE
Allergies
DISEASE
:Penicillins / SulfonamidesAttending:[**First Name3 (LF) 338**]Chief Complaint:Found unresponsive by friends.Major Surgical or Invasive Procedure:Endotracheal intubationVentriculostomyLumbar puncturesHistory of Present Illness:41 year-old female with a PMHx significant for
major depression
DISEASE
and
migraine headaches
DISEASE
transferred from Mt. [**Hospital 4257**] Hospitalwhere she was brought after being found unresponsive by herfriends.Per report Ms. [**Known lastname 4258**] was diagnosed with
otitis
DISEASE
media in theweek prior to admission and treated with Z-pac and cortisporinear drops. 2 days PTA she complained of a severe
headache
DISEASE
Admission Date: [**2155-10-28**] Discharge Date: [**2155-11-11**]Date of Birth: [**2098-5-26**] Sex: MService: [**Hospital1 **]CHIEF COMPLAINT: Change in mental status.HISTORY OF PRESENT ILLNESS: This is a 57-year-old gentlemanwith a complicated past medical history including end-stage
renal disease
DISEASE
on hemodialysis
insulin-dependent diabetes
DISEASE
mellitus
DISEASE
chronic
MRSA infection
DISEASE
of an aorto-aortic graftaortic dissection status post repair in [**2143**] coronary arterydisease status post coronary artery bypass grafting whopresented with a three-week history of increased
confusion
DISEASE
and
somnolence
DISEASE
.According to the patient's family the patient had a slowlydeclining mental status over the past three monthsAdmission Date: [**2166-12-29**] Discharge Date: [**2167-1-2**]Date of Birth: [**2096-10-9**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4272**]Chief Complaint:70 y/o female w/ asymptomatic LUL nodule found on routine PECXRAY by PCP. [**Name10 (NameIs) 4273**] constitutional symptoms.Major Surgical or Invasive Procedure:LUL lobectomy for LUL noduleHistory of Present Illness:70 y/o female w/ asymptomatic LUL nodule found on routine PECXRAY by PCP [**Name10 (NameIs) **] Constitutional symptoms.Past Medical History:
HTN
DISEASE
MR
RA
DISEASE
Lumbar fusion [**2161**]TTE: LVEF Admission Date: [**2169-12-5**] Discharge Date: [**2169-12-5**]Date of Birth: [**2096-10-9**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2736**]Chief Complaint:
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:Cardiac catheterizationHistory of Present Illness:73 y/o M with h/o lung CA renal CA s/p right proximeralfemoral resection and reconstruction with
tumor
DISEASE
prosthesis[**11-14**] recently d/c from [**Hospital1 18**] [**2169-11-22**] to rehab..Patient was refered to the Ed after VNA call physician with
hypotension
DISEASE
[**Name9 (PRE) 4280**] and low PO intake. On arrival patientwith
respiratory distress tachypneic
DISEASE
tachycardic. VS Hr 154Bp 189/88 RR 28 Sats 100%. EKG stE v2-v4 st
depression
DISEASE
v5 v6I and
AVL
DISEASE
. She was also tachycardic and adenosin Admission Date: [**2134-12-3**] Discharge Date: [**2134-12-7**]Date of Birth: [**2063-8-6**] Sex: MService: MEDICINE
Allergies
DISEASE
:Sulfa (Sulfonamide Antibiotics)Attending:[**First Name3 (LF) 783**]Chief Complaint:Chief Complaint:
fever
DISEASE
Reason for MICU transfer:
hypotension
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:A 71 year old male with PMH
Cholelithiasis
DISEASE
and
biliary colic
DISEASE
s/punsuccessful open cholecystectomy is called out of the MICUafter a one day hospitalization for
hypotension
DISEASE
following ERCP..According to the patient he had an episode of
abdominal pain
DISEASE
in[**9-/2134**] and presented to [**Hospital6 4287**] where he underwent anattempted laparoscopic cholecystectomy which was converted to anopen
proceedure
DISEASE
due to
fibrosis
DISEASE
. He reports that the surgeon wasable to remove some stones and closed leaving a bile drain inplace. He was then sent to [**Hospital1 18**] for ERCP on [**2134-10-28**] withbiliary stent placement which was successful. Following theprocedure the patient noted decreased output from the externalbiliary drain and had resolution of
abdominal pain
DISEASE
. On the dayof admission ([**2134-12-2**]) the patient presented for an repeat ERCPto place a larger biliary stent which was performedsuccessfully. He returned home where he noted
chills
DISEASE
and an oraltemperature of 100.7. He called his PCP who recommended referralto the ED. In the ED initial VS were: 98.3 78 91/52 18 94%Labs were remarkable for WBC 5.0 73%PMN 3% Bands he was givenamp/sulbactam and 2L IVNS and admitted to the MICU..While in the MICU antibiotics were changed to vancomycin andzosyn. Biliary drain fluid was cultured with initial gram stainshowing Gram Neg Rods and Gram positive
Cocci
DISEASE
and cultureshowing polymicrobial growth. ERCP fellow was [**Month/Day/Year 653**] whonoted that the fluid in a cholecystomy bag is rarely culturedand is likely to be colonized with non-pathogenic bacteria. Thepatient was given a total of 5 liters of fluid in the ED andMICU. BP has now been stable without requring fluid for over 24hrs and therefore patient was able to leave the MICU..On arrival to the floor patient denies any current complaintsand states that he feels as well as he normally does at home..REVIEW OF SYSTEMSOn review of systems he denies any prior history of
stroke
DISEASE
TIA
DISEASE
deep
venous thrombosis pulmonary embolism bleeding
DISEASE
at thetime of surgery
myalgias
DISEASE
joint pains cough hemoptysis
DISEASE
blackstools or red stools. He denies
exertional buttock
DISEASE
or
calf pain
DISEASE
.All of the other review of systems were negative..Cardiac review of systems is notable for absence of
chest pain
DISEASE
dyspnea
DISEASE
on
exertion paroxysmal nocturnal dyspnea orthopnea
DISEASE
ankle
edema palpitations syncope
DISEASE
or
presyncope
DISEASE
.Past Medical History:
HTN
DISEASE
hyperlipidemia
DISEASE
Type II DM
DISEASE
Status post carotid endarterectomy
Thrombocytopenia
DISEASE
Fibrotic
lung disease
DISEASE
: Likely due to
asbestosis
DISEASE
Bladder CA status post TURBTSocial History:Lives in [**Location 4288**] with his wife and son. Significant 30Admission Date: [**2132-7-9**] Discharge Date:Date of Birth: [**2098-11-23**] Sex: MService: Orthopaedic SurgeryHISTORY OF PRESENT ILLNESS: [**Known firstname **] [**Known lastname 4297**] is a 33-year-oldmale who was a restrained passenger in a 110 mile per hourmotor vehicle versus tree collision in [**Hospital3 4298**] on[**2132-7-8**]. The driver in the same vehicle was dead onarrival.The patient was transferred by med-flight from [**Hospital6 4299**] to the [**Hospital1 188**]. By report he was awake and alert at the outsidehospital. He was then sedated and intubated. He was notedto be tachycardic and
hypotensive
DISEASE
on arrival at [**Hospital1 346**]. Evidence of multiple
fractures
DISEASE
and
dislocations
DISEASE
.He was admitted to [**Hospital1 69**] on[**2132-7-9**]Admission Date: [**2199-7-13**] Discharge Date: [**2199-7-16**]Date of Birth: [**2116-9-4**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4309**]Chief Complaint:
chest pain
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:82F h/o prior CVA with residual R-sided weakness AS ([**Location (un) 109**] 1.2cm2) cecal and splenic flexure masses admitted with
chest pain
DISEASE
.Describes 3 days of
chest pain
DISEASE
that radiates across the chestoccuring only while supine at night describes as a constantAdmission Date: [**2139-11-24**] Discharge Date: [**2139-12-4**]Service: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 602**]Chief Complaint:
somnolence
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:This is an 87 year old lady with a PMH of diastolic heartfailure (EFAdmission Date: [**2199-7-28**] Discharge Date: [**2199-8-5**]Date of Birth: [**2116-9-4**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2610**]Chief Complaint:
Chest pain
DISEASE
and bright red blood per rectumMajor Surgical or Invasive Procedure:Colonoscopy [**2199-8-2**]Bleeding scan [**2199-7-30**]Transfused 6 units PRBCHistory of Present Illness:82 yo F with hx of prior CVA with residual R-sided weakness AS([**Location (un) 109**] 1.2 cm2) known cecal and splenic flexure masses recentlyadmitted for sub-sternal chest pressure in the setting of BRBPRand a Hct of 20.8 presents with substernal chest pressure insetting of BRBPR..Of note the patient was admitted from [**2199-7-13**] through [**2199-7-16**]with BRBPR acute on chronic
anemia
DISEASE
and
chest pain
DISEASE
with ECGchanges. The patient was observed in the MICU for 1 day andgiven a total of 4pRBCs on [**2199-7-13**] that brought her Hct from20.8 to 30.8. The patients
chest pain
DISEASE
subsequently resolved andshe was discharged home. There was a recommendation for taggedRBC scan during that admission however she had no furtherepisodes of
bleeding
DISEASE
during the hospitalization..Since discharge the patient has had mulitple episodes of BRBPR.Last night the pt noted Admission Date: [**2186-12-11**] Discharge Date: [**2186-12-13**]Date of Birth: [**2136-6-19**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1711**]Chief Complaint:CHEST PAINMajor Surgical or Invasive Procedure:CatheterizationHistory of Present Illness:Mr. [**Known lastname 4318**] is a 50 yo M with history of prior anterior MI s/pDES to
LAD
DISEASE
in [**8-29**] who presented to ED after experiencing CPsince 9am and found to have inferior STE. He was working on histruck this am when he started to have
chest tightness
DISEASE
and
diaphoresis
DISEASE
that felt similar to his prior heart attack. Herated it as a [**8-4**]. The night prior he said he took an antacidfor what he thought was gas
pain
DISEASE
. He says he had not taken anyof his medications in 6 months except his aspirin. He hadco-workers call 911..In the ED initial vitals were 78 118/87 16 100%NRB. Givennitro morphine plavix 600mg and started on integrillin.He was taken to cath where he has near occlusion of OM andunderwent export thrombectomy followed by direct stenting with a3.0x15mm
Endeavor
DISEASE
post-dilated to 3.25mm. An LVgram showed EFin 40% marked
LV dysfunction
DISEASE
40% (anterior apical andposterolateral HK). LVEDP Admission Date: [**2189-1-15**] Discharge Date: [**2189-1-17**]Date of Birth: [**2136-6-19**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 4327**]Chief Complaint:STEMIMajor Surgical or Invasive Procedure:[**2189-1-15**] - Left heart cardiac catheterization with bare metalstent placed in the LADHistory of Present Illness:52 year old male with
coronary artery disease
DISEASE
s/p
MI
DISEASE
s/p PCI toLAD and LCx ([**2181**] [**2186**]) and s/p right
atrial tachycardia
DISEASE
ablation [**6-/2188**] with decreased ejection fraction (EF 20% from40% in [**2186**]) presenting with
chest pain
DISEASE
found to have STEMIenroute by EMS. Patient woke up 3:30 am this morning at homeand reports tightness across his chest not localizing anywherespecific. Patient reports the
chest pain
DISEASE
is similar to his pastMI 4 years ago when he got stents placed in the LAD. He took325 aspirin PO before he got here. he is
clammy
DISEASE
.
pain
DISEASE
was [**5-4**]initially. After nitro the
pain
DISEASE
was [**2-4**]. He was takinglisinopril metaprolol. Stopped taking those meds because he ranout refills no other reason..In ED he was 80 BP 138/100 Resp 20 O2 Sat 100%. EKG noted STEin V1-V4 with Qs in II III AVF. Exam was notable for
diaphoresis
DISEASE
and
chest tightness
DISEASE
40 min prior to presentation.Labs were notable for trop of 0.01 otherwise benign. He wasgiven plavix heparin gtt taken to the cath [**Month/Year (2) **] for urgentintervention. He was found to have LAD in stent
thrombosis
DISEASE
used 160cc of dye was given
bival
DISEASE
in labs. BMS x 1 to LAD RFAaccess. Angiosealed..In CCU patient appeared to be in good spirit..On review of systems s/he denies any prior history of
stroke
DISEASE
TIA
DISEASE
deep
venous thrombosis pulmonary embolism bleeding
DISEASE
at thetime of surgery
myalgias
DISEASE
joint pains cough hemoptysis
DISEASE
blackstools or red stools. S/he denies recent
fevers chills
DISEASE
orrigors. S/he denies
exertional buttock
DISEASE
or
calf pain
DISEASE
. All of theother review of systems were negative..Cardiac review of systems is notable for absence of
chest pain
DISEASE
dyspnea
DISEASE
on
exertion paroxysmal nocturnal dyspnea orthopnea
DISEASE
ankle
edema palpitations syncope
DISEASE
or
presyncope
DISEASE
..Past Medical History:1. CARDIAC RISK FACTORS: -Diabetes Admission Date: [**2136-6-10**] Discharge Date: [**2136-7-11**]Date of Birth: [**2093-2-11**] Sex: MService: MEDICINE
Allergies
DISEASE
:Thorazine / Haldol / Risperdal / Codeine / Demerol / DarvonAttending:[**First Name3 (LF) 898**]Chief Complaint:CC:[**CC Contact Info 4329**]Major Surgical or Invasive Procedure:L. 1st MPJ arthrocentesis [**2136-6-20**]I&D Left Lower Extremity [**2136-6-13**]PICC LINE placement. [**2136-6-25**]L 1st joint arthrocentesis [**2136-7-5**]History of Present Illness:HPI: 43 yo M with h/o
schizophrenia
DISEASE
and self-abusive behaviorresulting in recurrent
cellulitis
DISEASE
and [**Hospital 4330**] transferred to [**Hospital1 18**]for Admission Date: [**2132-7-9**] Discharge Date: [**2132-10-1**]Date of Birth: [**2098-11-23**] Sex: MService:ADMISSION DIAGNOSIS:IM roding of right femur open reduction and internalfixation of right femoral head rod left talus rightcaliectomy Admission Date: [**2185-11-22**] Discharge Date: [**2185-11-29**]Service:HISTORY OF PRESENT ILLNESS: This is an 80-year-old gentlemanwith a recent history of
exertional
DISEASE
chest discomfortpositive stress test was obtained and he was referred to[**Hospital1 69**] for cardiaccatheterization.PAST MEDICAL HISTORY:1.
Hypertension
DISEASE
.2.
Osteoarthritis
DISEASE
.3. Benign
prostatic hypertrophy
DISEASE
.4.
Chronic back pain
DISEASE
secondary to spinal stenosis.5. Lumbar
radiculopathy
DISEASE
.6. Known
coronary artery disease
DISEASE
with EKG evidence of prior
myocardial infarction
DISEASE
.7. Status post right rotator cuff repair.8. History of upper GI bleed.9.
Gastric ulcer
DISEASE
.10.
Vertigo
DISEASE
.MEDICATIONS UPON ADMISSION TO HOSPITAL:1. AndroGel 1% q.d.2. Atenolol 50 mg q.d.3. Lipitor 40 mg q.d.4. Colace 100 mg t.i.d.5. Lisinopril unknown dose.6. Neurontin 300 mg q.h.s.7. Nitroglycerin 0.4 mg sublingual prn.8. Norvasc 10 mg p.o. q.d.9. Nitro patch 0.2 q.d.10. Protonix 40 mg q.d.11. Quinine 260 mg h.s.12. Tylenol with codeine #3 prn.13. Ultram q.i.d. prn.14. Vioxx 12.5 b.i.d. prn.ALLERGIES: The patient states no known
drug allergies
DISEASE
.Echocardiogram obtained in [**2185-3-8**] revealed leftventricular ejection fraction 60% dilated ascending aortaand mild
aortic stenosis
DISEASE
and mild mitral annular
calcification
DISEASE
.Catheterization obtained revealed LVEDP of 17 90% left mainstenosis 80% proximal right
coronary artery stenosis
DISEASE
. Dueto the anatomy of the patient's lesions an intra-aorticballoon pump was inserted in the Cardiac CatheterizationLaboratory and he was taken to the Coronary Care Unitpreoperatively.Laboratory values upon admission to the hospital wereunremarkable with the exception of a creatinine of 1.2.PHYSICAL EXAMINATION UPON ADMISSION TO THE HOSPITAL: Wasalso unremarkable.Patient was taken to the operating room on [**2185-11-23**]by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] cardiothoracic surgeon. Patientunderwent coronary artery bypass graft x3 with a LIMA to theLAD saphenous vein to the right coronary and a saphenousvein to the obtuse marginal. Postoperatively he wastransported in good condition from the operating room to theCardiac Surgery Recovery Unit.The night of surgery the patient was weaned from mechanicalventilation and extubated successfully. On postoperative dayone he was off vasoactive drips. He was hemodynamicallystable. His intra-aortic balloon pump was discontinued. Hewas begun on Lasix as well as a beta blocker.Later in the day on postoperative day one the patient wastransferred from the Intensive Care Unit to the telemetryfloor in good condition.In postoperative day two the patient remainedhemodynamically stable. He was transfused 1 unit of packedred blood cells for a hematocrit of 23. He was begun withPhysical Therapy and cardiac rehabilitation. He continued onLopressor and Lasix. Patient continued to progress over thenext couple of days with cardiac rehabilitation increasingmobility and ambulating with less assistance. Patient didreceive a total of 3 units of packed red blood cells onpostoperative day two to postoperative day three for a dropin hematocrit.On postoperative day four patient continued to work withaggressive physical therapy. He was still not completelyindependent at that time but was progressing in satisfactorycondition. Today on postoperative day six the patientremained hemodynamically stable and ready to be dischargedto home.Patient's condition today is as follows: He is afebrile.His weight is 68.4 kg today which is just about hispreoperative weight of 68 kg. His wounds are clean dry andintact. His lungs are clear to auscultation bilaterally.His abdomen is soft nondistended and nontender. He has 1Admission Date: [**2160-10-12**] Discharge Date: [**2160-10-15**]Date of Birth: [**2101-11-10**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 783**]Chief Complaint:difficulty walking
abdominal fullness
DISEASE
Major Surgical or Invasive Procedure:Placement of femoral central line with subsequent removalOne episode of hemodialysisfoley catheter placementHistory of Present Illness:This is a 58yoM with history of DM HTN HLD
obesity
DISEASE
whopresents from urgent care clinic with grossly abnormal labs..Patient was in USOH until beginning of [**Month (only) 359**] when he developedlower
back pain
DISEASE
. After seeing his PCP [**Name10 (NameIs) **] was started onTylenol#3 and flexeril. He then represented on [**10-3**] for severe
constipation
DISEASE
x 3 days. He was started on MOM with good results.At this appt he also complained of
dysuria
DISEASE
for which urineculture was obtained and was negative. He represented again on[**10-11**] for severe
constipation
DISEASE
. Plan was to try OTC drugs andfollow up on [**10-12**]. Per office note patient appeared weak andhad protuberant abdomen. KUB from office note showed evidence ofAdmission Date: [**2143-1-29**] Discharge Date: [**2143-2-4**]Date of Birth: [**2074-5-22**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4365**]Chief Complaint:altered mental statusMajor Surgical or Invasive Procedure:noneHistory of Present Illness:Mr. [**Known lastname 174**] is a 68 year-old man with
IgA meyloma
DISEASE
s/p Velcade(last treatment [**2143-1-4**])
DM2 CKD
DISEASE
and
schizophrenia
DISEASE
whopresents from his [**Hospital3 **] with
confusion
DISEASE
and is admittedto the MICU for sepsis/hypotension..He was in his USOH until three days ago when nursing staffnoticed that he was more confused. Today he was noted by staffto have high finger sticks (glucose Admission Date: [**2147-9-8**] Discharge Date:Service:ADDENDUM: Remove Captopril from the discharge medication listand add Prinivil 40 mg by mouth every day. For the medicationDiflucan change the strength from 400 mg to 100 mg by mouthevery day times two more days.Add to follow-up instructions the patient is to follow-upwith Dr. [**Last Name (STitle) **] as an outpatient and she is to follow-upwith the [**Hospital1 69**] [**Hospital 2663**]Clinic for an endometrial biopsy. This clinic can be reachedat area code [**Telephone/Fax (1) 2664**].Dictated By:[**Name8 (MD) 2665**]MEDQUIST36D: [**2147-9-20**] 13:06T: [**2147-9-20**] 14:48JOB#: [**Job Number 2666**]Admission Date: [**2147-9-8**] Discharge Date: [**2147-9-20**]HISTORY OF PRESENT ILLNESS: The patient is an 88 year oldfemale with
coronary artery disease congestive heart failure
DISEASE
and
diabetes mellitus
DISEASE
who presented with
fever
DISEASE
abdominal
pain
DISEASE
after being found down at her nursing home. Her historypatient is a resident at [**Hospital3 2558**] who was found statuspost questionable fall the morning of admission and was notedto have a left-sided weakness without
head trauma
DISEASE
or loss ofconsciousness. The fall was unwitnessed. Subsequently thepatient had a large occult blood positive stool and was alsofound to have complaints of
abdominal pain
DISEASE
. At the nursinghome the temperature was 102.1 with a pulse of 126 bloodin by ambulance to [**Hospital6 256**]Emergency Department for evaluation with a temperature of103.2 pulse 120 blood pressure 108/40 and respiratory rateof 30 with an oxygen saturation of 94%. In the EmergencyDepartment the patient was found to have an increasedrespiratory rate. She denied
cough chest pain shortness
DISEASE
of
breath nausea
DISEASE
and
vomiting
DISEASE
or
dysuria
DISEASE
. She did complain of
abdominal pain
DISEASE
and
diarrhea
DISEASE
. The patient is demented atbaseline. The patient denied any
fevers
DISEASE
or
chills
DISEASE
priorthough it is unclear but it is possibly p.o. intake had beendecreased for several days.PAST MEDICAL HISTORY: Coronary
artery disease
DISEASE
status post
congestive heart failure
DISEASE
with last admission in [**2144-4-5**]for
diastolic heart failure Type 2 diabetes dementia
DISEASE
benign
positional vertigo
DISEASE
status post cholecystectomystatus post
femoral neck fracture
DISEASE
on the right with ahemiarthroplasty chronic
anemia
DISEASE
with hematocrit of 29 and
B12 deficiency
DISEASE
.ALLERGIES: Benzodiazepine which causes severe
agitation
DISEASE
.ADMISSION MEDICATIONS:1. Multivitamin2. Enteric coated Aspirin 325 mg p.o. q.d.3. Lasix 40 mg p.o. q.d.4. Prinivil 30 mg p.o. q.d.5. Megace 400 mg p.o. b.i.d.6. Lopressor 25 mg p.o. b.i.d.7. Isordil 30 mg p.o. t.i.d.8. Neurontin 100 mg p.o. q. 69. Colace 100 mg p.o. b.i.d.PHYSICAL EXAMINATION: Physical examination revealed atemperature of 103.2 pulse 120 blood pressure 108/40 andrespiratory rate of 30 and oxygen saturation of 94%. Thepatient was an awake alert tachypneic elderly white femalein mild distress. Pupils were left surgical minimallyreactive right reactive. Extraocular muscles grosslyintact. Oropharynx mucous membranes were dry edentulous.Neck was supple with jugulovenous distension of 10 cm no
lymphadenopathy
DISEASE
. Cardiovascular examination tachycardiacnormal S1 and S2. Lungs with
decreased breath sounds
DISEASE
bilaterally anteriorly at the bases otherwise clear toauscultation. Abdomen was diffusely tender with bowelsounds no masses no
organomegaly
DISEASE
and mild distention.Occult blood positive brown stool per the EmergencyDepartment. Back examination positive costovertebral angle
tenderness
DISEASE
bilaterally per Emergency Department. Extremitieswith 1Admission Date: [**2139-12-25**] Discharge Date: [**2139-12-31**]Service: ORTHOPAEDICS
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name8 (NamePattern2) 1103**]Chief Complaint:
Right subtrochanteric femur fracture
DISEASE
Major Surgical or Invasive Procedure:[**2139-12-26**] - Trochanteric femoral nail for right subtrochantericfemur
fracture
DISEASE
History of Present Illness:87F s/p fall this AM transferred here from [**Hospital3 2005**]for R subtrochanteric femoral fx. She states she currentlydoesn't have any
pain
DISEASE
. She does not know how she fell. She wasfound by her aid at home on the floor by her bed. She denies HACP neck pain. She was recently admitted to the MICU for
CHF
DISEASE
exacerbation from [**2139-11-24**] to [**2139-12-4**]Past Medical History:1. Falls multiple noted in OMR & D/C summaries2.
Pulmonary HTN
DISEASE
on 2L/nc Admission Date: [**2138-11-8**] Discharge Date: [**2138-11-9**]Date of Birth: [**2055-4-30**] Sex: FService: MEDICINE
Allergies
DISEASE
:VicodinAttending:[**First Name3 (LF) 1257**]Chief Complaint:ThirstMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:83 year old woman with PMR on prednisone recently onazathioprine IDDM CKD Stage 3 and h/o colon CA s/p resection[**2122**] presenting with
thirst hypovolemia hyperglycemia
DISEASE
and
hyperkalemia
DISEASE
. Patient reports persistent
diarrhea
DISEASE
[**5-22**] loose
watery dark black-green stools
DISEASE
per day x last week attributed toazathioprine which was subsequently discontinued 2 days PTA. Hadtrace blood on tissue but no
hematochezia
DISEASE
. She took immodiumyesterday and had some mild improvement in her symptoms but
diarrhea
DISEASE
has persisted today. She had mild crampy lower
abdominal pain
DISEASE
and chest pressure several days ago now bothresolved. CP was associated with indigestion and improved withmaalox. Overall she has been feeling unwell for last week butdenies
fever
DISEASE
or
chills
DISEASE
and reports good PO intake. She wasrecently restarted on prednisone approx. 1 month ago and hasnoted overall weight gains [**Last Name (un) 2675**] that time but no change in LE
edema
DISEASE
. Also reports SOB for months which is stable.
Denies
DISEASE
cough dysuria
DISEASE
current abd
pain
DISEASE
CP N/V. Finger sticks athoemhave been high 200s..In the ED initial vs were: 98.0 112 145/57 20 99%RA. Initiallabs significant for [**Last Name (un) **] with Cr 1.8 from 1.6 glucose 500s K8.8 7.9 on repeat Na 122. In the ED she received 2LNS 1 ampbicarb 30 kayexalate 20 units IV insulin and glucose improvedto 170s and K improved to 5.3. ECG revealed sinus tach nopeaked Ts or other signs of
hyperkalemia
DISEASE
. Had CT abdomen whichwas overall negative for acute process. Has had persistentlyhigh lactate 2.7-2.8. Now being admitted to MICU with
tachycardia
DISEASE
and elevated lactate. VS prior to trasnfer: 97.8119/57 119 20 99%RA 100%2L..On the floor she complains mostly of
thirst
DISEASE
and
dry mouth
DISEASE
andotherwise denies other complaints as above..Review of systems:(Admission Date: [**2169-1-24**] Discharge Date: [**2169-3-1**]Date of Birth: [**2095-1-13**] Sex: MService: COLORECTAL SURGERY SERVICEHISTORY OF PRESENT ILLNESS: This is a 74 year old gentlemanwith a history of
prostate cancer
DISEASE
who presented in [**Month (only) 1096**]of last year with
rectal bleeding
DISEASE
. Evaluation included acolonoscopy which showed an
ulcerative lesion
DISEASE
in the rectum.These were biopsied and showed moderately differentiated
adenocarcinoma
DISEASE
. The patient presents for curative resection.PAST MEDICAL HISTORY:
Prostate cancer
DISEASE
with radiationimplants and external beam radiationAdmission Date: [**2169-1-24**] Discharge Date: [**2169-3-1**]Date of Birth: [**2095-1-13**] Sex: MService:ADDENDUM: This is a continuation of the previously dictateddischarge summary dated [**2169-2-27**] an update of the patient'scondition.Mr. [**Known lastname 2684**] was initially started on Imodium for highileostomy outputs totaling 2-3 liters per day. This had beencoming down at the time of beginning the Imodium to about 2Admission Date: [**2169-5-6**] Discharge Date: [**2169-5-9**]Date of Birth: [**2095-1-13**] Sex: MService:HISTORY OF PRESENT ILLNESS: The patient is a 74-year-oldgentleman with a history of rectal
adenocarcinoma
DISEASE
and isstatus post proctosigmoidectomy with coloanal anastomosis andloop ileostomy with multiple admissions for partialsmall-bowel obstructions who now presents with
lightheadedness
DISEASE
and
vomiting
DISEASE
.The patient was last discharged from this hospital on [**2169-4-28**] after a 1-week admission for a partial small-bowelobstruction. This was his third documented episode of a
partial small-bowel obstruction
DISEASE
since his surgery in [**2168-12-28**]. The patient reports that he was doing well at thetime of discharge with good oral intake. Moreover over thatperiod time he had been told by both his urologist and hisprimary care physician to drink plenty of water to help withhis
prostatic hypertrophy
DISEASE
.Then over the next two to three days prior to admission thepatient reported a few episodes of lightheadedness feelingthat he might feel faint. He denied any accompanying chest
pain
DISEASE
shortness of breath or palpitations. This occurredwhen he was standing and ambulating and resolved with rest.Subsequently this afternoon he reports the onset of
nausea
DISEASE
with
clear emesis
DISEASE
times one (there were no coffee grounds orfrank blood in the
emesis
DISEASE
). With this he called his primarycare physician who instructed him to proceed to the EmergencyDepartment. He reports that his ostomy output has been more
watery
DISEASE
but he is uncertain whether it has increased involume.In the Emergency Department he was noted to have serumsodium of 107Admission Date: [**2133-6-13**] Discharge Date: [**2133-6-29**]Date of Birth: [**2064-9-21**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2074**]Chief Complaint:L sided CP [**7-4**] Admission Date: [**2133-7-29**] Discharge Date: [**2133-8-10**]Date of Birth: [**2064-9-21**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2704**]Chief Complaint:
chest pain
DISEASE
and
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:Coronary angiogramIntra-aortic balloon pumpPeritoneal dialysisHistory of Present Illness:68yo man w/ 3 vessel CAD s/p STEMI w/ stenting of LAD ([**5-30**])NSTEMI w/ DES to LCx ([**6-30**]) and
ESRD
DISEASE
on Peritoneal dialysis whop/w
chest pain
DISEASE
and
shortness of breath
DISEASE
. The CP is substernalsharp radiating to lower neck occurs both at rest & w/activity. No palliative factors.Past Medical History:1. CAD (3VD s/p STEMI [**5-30**] s/p BMS to LAD complicated by
cardiogenic shock
DISEASE
requiring balloon pump and intubation)**Severe
cardiomyopathy
DISEASE
(EF 15%)2.
ESRD
DISEASE
[**2-26**] PCKD on PD3.
Prostate Cancer
DISEASE
treated with neoadjuvant hormonal therapyfollowed by external beam radiation therapy4.
Anemia
DISEASE
of CD5. PVD with LE claudication (on plavix)6. H/O
GIB
DISEASE
Social History:Former smoker no EtOH. Lives with his wife.Family History:N/CPhysical Exam:Afebrile HR 100 BP 96/67 O2 96% on 2L NCTGen: alert awake oriented mild distressHEENT: increased JVP no LAD dry oral mucosaPulmonary: bibasilar cracklesCardiac: sinus tach Nml S2S2Abd: soft Admission Date: [**2135-11-28**] Discharge Date: [**2135-12-6**]Service:HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is an 88 year old womanwith a history of
hypertension hypercholesterolemia
DISEASE
andcritical
aortic stenosis
DISEASE
referred to Dr. [**Last Name (Prefixes) **] forreplacement of her aortic valve. The patient was scheduledfor surgery on [**2135-11-1**] and on preoperative workup was foundto have a
pseudomonas urinary tract infection
DISEASE
. Surgery wasrescheduled. Cardiac catheterization showed aortic valvearea of 0.6 centimeter squared mild to moderate
mitral
regurgitation
DISEASE
and ejection fraction of 55%.PAST MEDICAL HISTORY:1. Aortic stenosis.2.
Hypertension
DISEASE
.3.
Hypercholesterolemia
DISEASE
.4. Glaucoma.5.
Irritable bowel syndrome
DISEASE
.6.
Gastroesophageal reflux disease
DISEASE
.7. Pneumonia.8. Status post total abdominal hysterectomy bilateralsalpingo-oophorectomy.9. Status post appendectomy.ALLERGIES: The patient is
allergic
DISEASE
to Codeine which causesfacial swelling. The patient is
allergic
DISEASE
to Celexa.MEDICATIONS ON ADMISSION:1. Carvedilol 3.125 mg p.o. twice a day.2. Latanoprost 0.005% ophthalmic drops one drop both eyesq.h.s.3. Protonix 40 mg p.o. once daily.4. Lipitor 20 mg p.o. once daily.HO[**Last Name (STitle) **] COURSE: The patient was admitted to [**Hospital1 346**] on [**2135-11-28**] and was taken to theoperating room on [**2135-11-30**] with Dr. [**Last Name (Prefixes) **] for anaortic valve replacement with 19 millimeter pericardialvalve. Please see operative note for further details. Thepatient tolerated the procedure well and was transferred tothe Intensive Care Unit in stable condition. The patient wasweaned the next day from mechanical ventilation on the firstpostoperative night. Postoperatively the patient was foundto be significantly
hypertensive
DISEASE
and started on Nipride andNitroglycerin as well as Lopressor. On postoperative daynumber one the pulmonary artery catheter was removed. Onpostoperative day number two chest tubes were removed. Thepatient's oral antihypertensives were increased and bypostoperative day number three the patient was weaned offthe Nitroglycerin and transferred from the Intensive CareUnit to the regular part of the hospital. The patient wasrequiring only Tylenol for
pain
DISEASE
relief. The patient wasevaluated by physical therapy and it was felt that thepatient would benefit from a stay at short termrehabilitation. The patient's pacing wires were removedwithout incident. By postoperative day number five thepatient was cleared for discharge to rehabilitation facility.CONDITION ON DISCHARGE: Temperature maximum 98.4 pulse 86sinus rhythm blood pressure 122/53 respiratory rate 16 inroom air oxygen saturation 94%. Neurologically the patientis awake alert and oriented times three nonfocalambulating from bed to the bathroom without assistance.Cardiovascular is regular rate and rhythm without rub ormurmur. Breath sounds are clear bilaterally. The abdomen issoft nontender nondistended. The patient is toleratingregular diet. Sternal incision is clean dry and intact andthere is no
erythema
DISEASE
or drainage.LABORATORY DATA: White blood cell count 11.8 hematocrit34.3 platelet count 146000. Sodium 137 potassium 3.6chloride 97 bicarbonate 32 blood urea nitrogen 11creatinine 0.5 glucose 95.MEDICATIONS ON DISCHARGE:1. Colace 100 mg p.o. twice a day.2. Enteric Coated Aspirin 325 mg p.o. once daily.3. Tylenol 650 mg every four hours p.r.n.4. Furosemide 40 mg p.o. twice a day times seven days.5. Potassium Chloride 20 mEq p.o. once daily times sevendays.6. Lopressor 100 mg p.o. three times a day.7. Captopril 50 mg p.o. three times a day.8. Latanoprost 0.005% one drop each eye q.h.s.9. Protonix 40 mg p.o. once daily.10. Lipitor 20 mg p.o. once daily.DISCHARGE STATUS: The patient is to be discharged torehabilitation in stable condition.DISCHARGE DIAGNOSES:1. Aortic stenosis.2. Status post aortic valve replacement.3.
Hypertension
DISEASE
. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**] M.D. [**MD Number(1) 414**]Dictated By:[**Last Name (NamePattern1) 1541**]MEDQUIST36D: [**2135-12-5**] 18:46T: [**2135-12-5**] 19:00JOB#: [**Job Number 2711**]Admission Date: [**2117-1-9**] Discharge Date: [**2117-1-19**]Service: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 2712**]Chief Complaint:FallMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:This is an 89 year old male with past medical history of
diverticulosis
DISEASE
and
melanoma
DISEASE
who presented with with alteredmental status after a fall. The exact details of what happenedare a bit unclear as patient is not able to give a full historybut on [**2117-1-9**] the patient was shoveling snow when he sustaineda fall and struck his head. He managed to get inside and callhis daughter who came to check on him and found him veryconfused but able to speak with blood visible outside and insidethe house. She brought the patient to the ED where he had headCT revealing intraparenchymal and subdural
hemorrhages
DISEASE
andneurosurgery was consulted. They recommended no acuteneurosurgical management at the time. Patient was extremelyconfused and becoming less responsive at that time so he wasemergently intubated for airway protection and admitted to theneurosurgery ICU. Of night he had a CT of his chest abdomenand pelvis that night which was remarkable for signs ofaspiration as well as some free air in his abdomen. Hisabdominal exam was benign and surgery evaluated him feelingthere were no signs of an acute surgical abdomen or need forintervention.Past Medical History:-Diverticulosis-Melanoma R. Chest-Cataract-Pseudoexfoliation syndrome-HTN-Basal Cell CASocial History:Very independant care taker for his wife who has
dementia
DISEASE
Family History:NCPhysical Exam:PHYSICAL
EXAM
DISEASE
: in NICUO: T: af BP: 157/ 62 HR: 60 R :18 O2Sats99Gen: WD/WN trying to sit up on the stretcher at times.HEENT: Pupils: [**1-5**] bilaterally EOMis / no hemotympanumnoted / no csf rhinorrhea / no battles / no raccoons sign'sNeck: in cervical collar.Neuro: gcs eAdmission Date: [**2124-6-12**] Discharge Date: [**2124-7-8**]Date of Birth: [**2083-3-21**] Sex: MService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 301**]Chief Complaint:
GERD
DISEASE
and
small hiatal hernia
DISEASE
Major Surgical or Invasive Procedure:[**2124-6-12**]Laparoscopic converted to open redo Nissenfundoplication and repair of
hiatal hernia
DISEASE
.[**2124-6-16**]Esophagogastroduodenoscopy.[**2124-6-19**]1. Reopening of abdomen and washout of intraperitoneal
hematoma
DISEASE
.2. Endoscopy[**2124-6-27**]CT guided pigtail placement left pleural space[**2124-6-27**]CT guided drain placed in perisplenic fluid collectionHistory of Present Illness:41-year-old black gentleman status post Nissenfundoplication five years ago. He did great during this timewith no reflux or difficulty swallowing at all. He hadpreviously undergone endoscopic approaches to relieve his
heartburn
DISEASE
which had failed. However for the last two monthshe has had difficulty with some reflux as well as swallowingwater. Endoscopy revealed a small
hiatal hernia
DISEASE
and
gastritis
DISEASE
.A barium swallow showed a small
herniation
DISEASE
of the GE junctionpossibly above the diaphragm. He complains of these problemswith swallowing and also notes more frequent burping.Past Medical History:
Episcleritis
DISEASE
bilaterally: Followed by Dr. [**Last Name (STitle) **].
GERD
DISEASE
s/p Nissen Fundoplication
Obesity
DISEASE
Hypercholesterolemia
DISEASE
: Borderline in the past.Chronically elevated liver function tests: Normal evaluation inthe past.Chronic low back
pain
DISEASE
Hypertension
DISEASE
.s/p distal biceps tear and repair on [**2119-9-8**] by Dr. [**Last Name (STitle) 2719**].Social History:The patient states that he drinks beer occasionally on theweekends. He smokes occasional cigars but is exposed tosecondhand smoke at home. The patient smoked while he was inmilitary but quit over 10 years ago.Family History:Mother has a history of
migraine headaches
DISEASE
. His mother has ahistory of
diabetes
DISEASE
. Uncle has a history of
lung cancer
DISEASE
. He hasfour children who are all healthy.Physical Exam:Vital signsTemperature of 97.2 blood pressure 143/92 O2 sat 99% pulse84 Resp 20 weight 236 pounds.Breathing comfortably.Abdomen is soft. Incision is well healed.Moving all extremities well.Pertinent Results:[**2124-6-14**] UGI : No evidence of leak. Slow passage of contrastfrom the esophagus into the stomach likely from
edema
DISEASE
withresidual barium within the distal esophagus.[**2124-6-16**] CT Abd/pelvis/CTA chest :1. Dense right lower lobe consolidation consistent with
pneumonia
DISEASE
. Largeleft
pleural effusion
DISEASE
with pleural enhancementAdmission Date: [**2150-7-23**] Discharge Date: [**2150-7-31**]Date of Birth: [**2069-12-20**] Sex: MService: NEUROSURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2724**]Chief Complaint:change in mental status at homeMajor Surgical or Invasive Procedure:noneHistory of Present Illness:Pt is a 80m who was transfered from OSH after he was found tohave a large acute right sided SDH with 10mm of midline shift.Pt was a MVA on Tuesday and was seen at [**Hospital 2725**] hospital with anegative workup. Tonight pt was found on the floor next to hischair at home and EMS was called.Pt had been complaining of some
dizziness
DISEASE
after his MVA and did have one episode of
vomiting
DISEASE
.Upon EMS arrival pt was reported to be awake and oriented toself only. He appeared drowsy but answered simple questionsappropriately. Pt was taken to OSH where CT head ultimatelyfound a
subdural hematoma
DISEASE
. Pt was then intubated for airwayprotection and to [**Hospital1 18**] for further care.Past Medical History:
Breast cancer
DISEASE
High cholesterol GERD
peripheral neuropathy
DISEASE
Type II DM
DISEASE
Social History:married childrenFamily History:ncPhysical Exam:T: 97.4 BP: 121/67 HR:81 R 16 O2Sats 100%Intubated and sedated.HEENT: Pupils: 2.5-2.0 bilateral EOMs unable to evaluateNeuro:Mental status: Intubated and sedated. Will follow simplecommandsin all four extremities appears to be moving symmetricallyCranial Nerves:I: Not testedII: Pupils equally round and reactive to light2.5 to 2.0mm bilaterally.VII: Face appears symetric.VIII: Hearing intact to voice.Motor: Moving all extremities equally and symetrically.Sensation: Intact to light touchPertinent Results:CT head shows large R sided acute SDH with maximalthickness 1.5cm and 7mm midline shift.Labs: Na 142 K 4.5 WBC 11.8 HCT 31.2 PLT 273 INR 1.2 PTT 20.4Brief Hospital Course:Pt was admitted to the ICU for close monitoring. He was given aloading dose of fosphenytoin. He was following commands and wasable to be extubated. Repeat CT should stable appearance. Hecontinued to be monitored closely. It was noted that he wasunable to speak on [**7-25**] but given that there were no otherlateralizing symptoms or signs the decision was made that hewould be monitored closely. His symptoms improved over thecourse of [**7-25**] and [**7-26**] and he was not taken to the OR. Hecontinued to have word-finding difficulty but he was able torespond to most questions with obvious comprehension. On [**7-26**] R
wrist pain
DISEASE
and
swelling
DISEASE
was noted and he was found to have awrist
fracture
DISEASE
which was casted by ortho. On [**7-27**] he developedan erythematous
rash
DISEASE
over his lower back and flank and he wastransitioned from dilantin to keppra for
seizure
DISEASE
prophylaxis.His exam continued to improved. He complained of posterior neck
pain
DISEASE
on [**2150-7-29**] - CT of
c-spine
DISEASE
done which showed degenerativechanges but no acute
fracture
DISEASE
. He was evaluated by PT/OT andfelt suitable for rehab. Upon discharge he was alert andoriented x3 only very minimally word finding issues fullmotors no pronator drift following commands.Medications on Admission:Gemfibrozil 600 twice dailyTamoxifen 20mg daily Protonix 40mgdaily MVI 1 tab dailyZolpedin 10mg qhs Metformin unknown doseand spiriva unknowndose.Discharge Medications:1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2times a day).2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 timesa day).5. Tamoxifen 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).6. Pantoprazole 40 mg Tablet Delayed Release (E.C.) Sig: One(1) Tablet Delayed Release (E.C.) PO Q24H (every 24 hours).7. Tiotropium Bromide 18 mcg Capsule w/Inhalation Device Sig:One (1) Cap Inhalation DAILY (Daily).8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3times a day).10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 timesa day).11. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) LozengeMucous membrane PRN (as needed) as needed for
sore
DISEASE
throat.12. Camphor-Menthol 0.5-0.5 %
Lotion
DISEASE
Sig: One (1) Appl TopicalQID (4 times a day) as needed for
rash
DISEASE
.13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)Injection ASDIR (AS DIRECTED).14. Levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 timesa day).15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H(every 6 hours) as needed for
pain
DISEASE
.16. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)as needed for
pain
DISEASE
.17. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day)as needed for
muscle spasm/stiffness
DISEASE
.Discharge Disposition:Extended CareFacility:[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at[**Hospital6 1109**] - [**Location (un) 1110**]Discharge Diagnosis:
Acute right subdural hematoma
DISEASE
Discharge Condition:Mental Status: Confused - sometimes.Level of Consciousness: Alert and interactive.Activity Status: Ambulatory - requires assistance or aid (walkeror cane).Discharge Instructions:Admission Date: [**2138-12-2**] Discharge Date: [**2138-12-12**]Date of Birth: [**2071-12-12**] Sex: MService: CARDIOTHORACIC SURGERYHISTORY OF THE PRESENT ILLNESS: This is a 66-year-old manwith a past medical history significant for coronary arterydisease status post coronary artery bypass grafting in[**2128-10-21**] at which time they performed a left internalmammary artery to the left anterior descending saphenousvein graft to the OM-I and OM-II sequential and saphenousvein graft to the PDA. He is also status post stenting ofhis saphenous vein graft to the OM-I OM-II territory in[**2135-3-21**] and PTCA and brachytherapy to the saphenousvein graft to the OM-I OM-II in [**2137-12-21**]. Thepatient also has a past medical history significant for
insulin-dependent diabetes mellitus hypertension
DISEASE
hypercholesterolemia depression
DISEASE
mild
dementia
DISEASE
history of
TIA
DISEASE
status post bilateral carotid endarterectomies in [**2134**].The patient is a 66-year-old male with a long-standinghistory of
coronary artery disease
DISEASE
who was admitted [**2138-12-2**] due to
unstable angina
DISEASE
with a troponin level rangingbetween 4.5 and 5.9. Cardiac catheterization was performedon [**2138-12-2**] which revealed a patent left internalmammary artery graft occluded OM-1 and OM-2 graft and a 90%occlusion in the in-stented segment of the PDA. The lastechocardiogram was performed in [**2137-5-21**] which revealed aleft ventricular ejection fraction of 40%.ADMISSION MEDICATIONS:1. Atenolol 50 mg p.o. q.d.2. Lipitor 40 mg p.o. q.d.3. Aspirin 325 mg p.o. q.d.4. Aricept 5 mg p.o. q.d.5. Zestril 20 mg p.o. q.d.6. Metformin 850 mg b.i.d.7. Terazosin 5 mg q.h.s.8. Paxil 5 mg p.o. q.d.9. Buspar 15 mg t.i.d.10. Depakote 750 mg b.i.d.11. Vitamin E.12. Nitroglycerin patch.13. Plavix which is being held.14. NPH insulin 12 units q.a.m. 8 units q.p.m. regularinsulin 4 units q.a.m.HOSPITAL COURSE: An off-pump redo coronary artery bypassgrafting was performed on [**2138-12-8**]. It was acoronary artery bypass grafting times one with the saphenousvein graft to the obtuse marginal via left thoracotomyincision.The patient was transferred to the Cardiac Surgery RecoveryUnit in stable condition on Neo-Synephrine at 0.6 microgramsper kilogram per minute and propofol in normal sinus rhythmat 57 beats per minute. He was extubated the same day ofsurgery without any incidents around 6:00 p.m.On postoperative day number one the patient had a low-gradetemperature at 100.3 in sinus rhythm at 88. The vital signswere stable. The white count was 9.1 hematocrit 31.3platelet count 147000 with an unremarkable physicalexamination. The plan was to continue to keep his bloodpressure down on Nipride and to start the patient on his p.o.medications as well as his p.o. diet. If able to wean offthe Nipride the plan was to transfer the patient to thefloor.On postoperative day number two the patient was mildlydisoriented however calm without complaints with his
pain
DISEASE
well controlled. He was still with a low-grade temperatureof 100.1 in sinus rhythm at 88 mildly
hypertensive
DISEASE
at170/88. On physical examination he had mild cracklesbilaterally otherwise his examination was benign. The planwas just to continue monitor his mental status and
pain
DISEASE
control.On postoperative day number three the patient was stillwithout complaints however still requiring a sitter for hisdisorientation. Currently afebrile. The vital signs werestable saturating at 94% on room air. The physicalexamination was benign. The plan was to go for a cardiaccatheterization this morning with a possible PTCA with plusor minus stenting of the stenotic area.He did undergo cardiac catheterization on [**2138-12-11**]which now revealed a saphenous vein graft to the obtusemarginal patent and a saphenous vein graft to the posteriordescending artery with a 90% distal stenosis with a 3 by 13mm stent with distal protection and 0% residual with normalflow. The plan was to continue the patient on aspirin andPlavix 75 mg p.o. daily for 30 days and to administerIntegrelin overnight.The anticipated date of discharge is [**2138-12-12**]. Thepatient is to be discharged home on the followingmedications.DISCHARGE MEDICATIONS:1. Metformin 850 mg p.o. b.i.d.2. Lisinopril 2.5 mg p.o. q.d.3. Sliding scale of insulin.4. Metoprolol 50 mg p.o. b.i.d.5. Divalproex 500 mg p.o. b.i.d.6. Buspar 15 mg p.o. t.i.d.7. Paxil 5 mg p.o. q.d.8. Atrovastatin 40 mg p.o. q.d.9. Plavix 75 mg p.o. q.d. for three months.10. Donepezil 5 mg p.o. q.h.s.11. Dulcolax milk of magnesia p.r.n.12. Percocet 5 one to two tablets p.o. q. 4-6 hours p.r.n.
pain
DISEASE
.13. NPH 3 units at breakfast 4 units at bedtime.14. Ibuprofen 400 mg q.i.d.15. Acetaminophen 650 mg q. four hours p.r.n.16. Aspirin 325 mg p.o. q.d.17. Colace 100 mg p.o. b.i.d.18. Lasix 20 mg p.o. b.i.d.19. Potassium chloride 20 mEq p.o. q.d.PLAN: The plan is for the patient to arrange a follow-upvisit with Dr. [**Last Name (STitle) 1537**] in one month Dr. [**Last Name (STitle) 120**] in one monthand his primary care physician in two to four weeks.CONDITION AT DISCHARGE: Good.DISCHARGE DIAGNOSIS: Coronary artery disease status postre-do off-pump coronary artery bypass grafting times one. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**] M.D. [**MD Number(1) 1540**]Dictated By:[**Doctor Last Name 2011**]MEDQUIST36D: [**2138-12-12**] 13:20T: [**2138-12-14**] 15:05JOB#: [**Job Number 2012**]Admission Date: [**2150-8-4**] Discharge Date: [**2150-8-18**]Date of Birth: [**2069-12-20**] Sex: MService: NEUROSURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 78**]Chief Complaint:Worsening Mental Status with known SDHMajor Surgical or Invasive Procedure:[**2150-8-5**] Right Craniotomy and evacuation of SDHHistory of Present Illness:Mr [**Known lastname 2727**] was admitted to our service from [**Date range (1) 2728**] with a rightsided
subdural hematoma
DISEASE
. He was treated conservatively andmonitored his mental status and word finding difficulty improvedby discharge five days ago. He has been at a rehab facilitysince discharge when the staff and his family noticed that hebegan to have word finding difficulty
confusion
DISEASE
and worsening
headache
DISEASE
. He had an outside CT which showed increase size ofsubdural so he was transferred here for further care.Past Medical History:
Breast cancer
DISEASE
High cholesterol GERD
peripheral neuropathy
DISEASE
Type II DM
DISEASE
Social History:married childrenFamily History:non-contributoryPhysical Exam:PHYSICAL
EXAM
DISEASE
Upon Admission:O:T 97.6 HR 66 BP 112/48 RR 14 SPO2 98%
RA
DISEASE
laying on stretcher. NAD. Admission Date: [**2130-11-13**] Discharge Date: [**2130-12-6**]Service: MICUHISTORY OF PRESENT ILLNESS: The patient is an 85-year-oldwoman with a history of
congestive heart failure
DISEASE
peripheral
vascular disease
DISEASE
Type 2
diabetes mellitus
DISEASE
and
Parkinson's
DISEASE
disease who was admitted after being found unresponsive athome. The patient was in her usual state of health until 1P.M. on the day of admission when she was found by hercousin who lives with her. The patient was unresponsiveapparently no longer than 30 seconds. She slumped forwardand EMS was called. There were no preceding
palpitations
DISEASE
shortness of breath chest pain
DISEASE
focal
weakness dysarthria
DISEASE
bowel or bladder incontinence
DISEASE
or
seizure
DISEASE
activity noted.EMS noted the patient to have a finger stick blood glucose of240
atrial fibrillation
DISEASE
on the monitor with a rate of 100blood pressure of 136/palp respiration rate of 4 andinitially unresponsive. Her pupils were equal round andreactive to light.The patient was intubated and during intubation she wasnoted to have increased
agitation
DISEASE
. She was given 2 mg ofVersed successfully intubated and sent to [**Hospital1 346**] where she was immediately broughtto the Medical Intensive Care Unit. Upon arrival she washemodynamically stable.PAST MEDICAL HISTORY:1. Congestive
heart failure
DISEASE
last echocardiogram in [**2130-8-14**] showed mild symmetric left ventricular hypertrophyan ejection fraction of greater than 55% and 1Admission Date: [**2118-7-28**] Discharge Date: [**2118-8-1**]Date of Birth: [**2066-5-1**] Sex: FService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 2736**]Chief Complaint:
chest pain
DISEASE
Major Surgical or Invasive Procedure:[**7-29**]
pericardiocentesis
DISEASE
History of Present Illness:This is a 52 year old female with PMHx of
hyperlipidemia
DISEASE
whopresents to the CCU tonight after her PCP sent her to [**Hospital1 18**]Emergency department for an enlarged heart on CXR.The patient's history begins about 5 weeks ago when sheexperienced left anterior chaest pain which woke her around 0500that mornig.
Pain
DISEASE
is worse with breathing and radiated into herleft arm and left side of the neck. She went to [**Hospital3 2737**](which records were obtained) and had an MI workup including 2sets of negative cardiac enzymes a negative stress test and anunremarkable echo. She also with CT scan for r/o PE which founda 5 mm nodule in the RUL but not other findings. Patient wasdischarged from the hospital with no clear diagnosis. Prior toonset of symptoms she denied any recent local or foreign travelor cough/cold symptoms.Patient continued to have
chest pain
DISEASE
over the next month.Earlier this week she started having
fevers chills
DISEASE
and nightsweats. Temperature taken at home was max 100.8. She didexperience some SOB and
nausea
DISEASE
but no
vomiting
DISEASE
. She presentedto an OSH where she refused labs as she had already undergoneworkup and was discharged with a Zpack. She noted continuedsymptoms and decided to see her PCP today who ordered a CXR andsaw
cardiomegaly
DISEASE
pleural and
pericardial effusion
DISEASE
and sent herto the ED.In the ED initial vitals were 18:04 8 99.2 106 116/72 20 97%.She was having [**8-12**]
pain
DISEASE
worse while lying supine and relievedsitting upright. Pt states
pain
DISEASE
in
chest neck upper abdomen
DISEASE
and upper back. Pt with some sob with exersion. Patient giventoradol IV and Zosyn 1L NS fentanyl. Pulses done at bedsideby cardiology fellow which revealed only 10 mmHg. Bedside echoshowed moderate to large
pericardial effusion
DISEASE
with right atrialdiastolic collapse and
impaired R ventricular
DISEASE
filling uponinspiration..On arrival to the CCU patient has an
aching pain
DISEASE
[**8-12**] withfamily at the bedside..REVIEW OF SYSTEMSOn review of systems s/he denies any prior history of
stroke
DISEASE
TIA
DISEASE
deep
venous thrombosis pulmonary embolism bleeding
DISEASE
at thetime of surgery
myalgias
DISEASE
joint pains cough hemoptysis
DISEASE
blackstools or red stools. S/he denies
exertional buttock
DISEASE
or calf
pain
DISEASE
. All of the other review of systems were negative..Cardiac review of systems is notable for absence of
chest pain
DISEASE
dyspnea
DISEASE
on
exertion paroxysmal nocturnal dyspnea orthopnea
DISEASE
ankle
edema palpitations syncope
DISEASE
or
presyncope
DISEASE
.Past Medical History:PAST MEDICAL HISTORY:1. CARDIAC RISK FACTORS:
Diabetes Dyslipidemia Hypertension
DISEASE
2. CARDIAC HISTORY:-CABG:-PERCUTANEOUS CORONARY INTERVENTIONS:-PACING/ICD:3. OTHER PAST MEDICAL HISTORY:-Intimal thickening in R carotid arteryHystectomy for
fibroids
DISEASE
Hemorrhoids recent negative colonoscopy 5 years agoMammogram one month prior- normal.MEDICATIONS:Pravastatin 40mg dailyDocusate sodium 100 mg daily
Lactobacillus Rhamnosus Gg 1 capsule daily
DISEASE
ALLERGIES: NKDASocial History:-Tobacco history: none-ETOH: occasional-Illicit drugs: none-Works for shoe store in inventory moving boxesFamily History:FAMILY HISTORY:Family history of CAD in grandparents at older age. Breast
cancer
DISEASE
in grandmother and
pancreatic cancer
DISEASE
in another relative.Physical Exam:PHYSICAL EXAMINATION:VS: TAdmission Date: [**2165-5-14**] Discharge Date: [**2165-5-17**]Service: MEDICINE
Allergies
DISEASE
:IodineAdmission Date: [**2168-12-3**] Discharge Date: [**2168-12-14**]Service: MEDICINE
Allergies
DISEASE
:IodineAdmission Date: [**2169-2-13**] Discharge Date: [**2169-3-2**]
Service: MEDICINE
Allergies
DISEASE
:Iodine-Iodine Containing / Ampicillin / Phenergan Plain /Zaroxolyn / AmbienAttending:[**First Name3 (LF) 2763**]Chief Complaint:
dyspnea
DISEASE
Major Surgical or Invasive Procedure:intubationHistory of Present Illness:Ms. [**Known lastname 2749**] is a [**Age over 90 **]yoF with severe diastolic HF NYHA class IVwith
multiple exacerbations
DISEASE
in past year
HTN
DISEASE
HLD
Afib
DISEASE
andgait abnormality related to Admission Date: [**2164-11-21**] Discharge Date: [**2165-1-1**]Date of Birth: Sex: FService:HISTORY OF PRESENT ILLNESS: Ms. [**Name14 (STitle) 2765**] is a 63-year-oldlady who was initially admitted to the Medical service at[**Hospital6 256**] after being transferredfrom an outside hospital.She has a long history of
end-stage renal disease
DISEASE
and isstatus post cadaveric kidney transplant. She has recentlybeen diagnosed with
gastric B cell lymphoma
DISEASE
and presents herefor further workup. This was prompted by symptoms of
abdominal pain
DISEASE
and diagnosed after EGD-obtained biopsy. Shehas had a history of
weight loss
DISEASE
night sweats
pruritus
DISEASE
andfeeling fatigued over the last few months.PAST MEDICAL HISTORY:1. Underwent cadaveric renal transplantation in [**5-/2156**] for
end-stage renal disease
DISEASE
secondary to
hypertension
DISEASE
.2. Osteoporosis.3. Total abdominal hysterectomy with bilateralsalpingo-oophorectomy.4. Peripheral
vascular disease
DISEASE
and was scheduled to undergoperipheral vascular bypass.5. Congestive
heart failure
DISEASE
.6. Appendectomy.7. Lumbar disc surgery.PHYSICAL EXAMINATION: She is an elderly lady in somedistress. She is afebrile. Blood pressure is 100/70 heartrate is 96. Chest and abdomen are clear to auscultation.Abdomen is distended and somewhat tender. Extremities arewithin normal limits.HOSPITAL COURSE: She was admitted to the hospital forfurther management. During the next 24 hours her abdominal
pain
DISEASE
and
tenderness
DISEASE
worsened. Nasogastric tube was placedfor decompression. After CAT scan and surgical evaluation itwas decided that she had an acute abdomen and we decided todo a laparotomy.On the laparotomy she was found to have extensive ganglion ofher
small bowel
DISEASE
. Most of her small bowel was resected andan
SMA
DISEASE
thrombectomy was performed by the Vascular Surgeryservice at the same time. A second-look laparotomy wasperformed the next day and more small bowel resected. Twodays later a third look was performed and small bowelreanastomosed. This left her with about 50 cm of smallintestine.She was kept in the Intensive Care Unit postoperatively andextensive discussions were had with the family and her poorprognosis explained to them. She was kept on totalparenteral nutrition and low-dose immunosuppression.Hematology/Oncology consultation was obtained and it wasfelt she was not stable enough to tolerate treatment for herlymphoma. She briefly developed
peritonitis
DISEASE
which resolvedwith antibiotic therapy. She was gradually started on oralswhich she tolerated surprisingly well. She was also able totake all of her oral medication. As expected we were notable to wean her off the TPN.She continued to be followed by the Renal andHematology/Oncology and Transplant services during thisadmission.Finally due to lack of improvement in her condition and asper her and the family's wishes she was transferred toHospice care.DISPOSITION: Transferred for palliative Hospice care.DISCHARGE DIAGNOSES:1. Acute
mesenteric ischemia
DISEASE
.2. End-stage
renal disease
DISEASE
.3.
Hypertension
DISEASE
.4. Gastric B cell lymphoma.5. Status post cadaveric kidney transplant. [**Name6 (MD) 1344**] [**Name8 (MD) 1345**] M.D.Dictated By:[**Name8 (MD) 2766**]MEDQUIST36D: [**2165-4-1**] 16:18T: [**2165-4-3**] 22:38JOB#: [**Job Number 2767**]Admission Date: [**2114-12-10**] Discharge Date: [**2114-12-18**]Date of Birth: [**2071-11-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:Penicillins / Bactrim / BaclofenAttending:[**First Name3 (LF) 562**]Chief Complaint:
fevers headache diarrhea hypoxia
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:The paitent is a 43-year-old male with a longstanding history ofHIV/AIDS who presented to the ED after a week long history ofhigh grade
fevers
DISEASE
and worseing
dyspnea
DISEASE
with exertion. Thepatient was diagnosed in [**2095**] with HIV and has been on and offHAART therapy since that time. Most recently he was on steadytreatment for 3 years until this spring when he decided to takea self decided medication holiday. He reports he has not takenHAART medications in about 6 months. About 2-3 months ago thepatient also started having
watery diarrhea
DISEASE
intermittently [**2-18**]times weekly. About one and a half weeks ago he startednoticing high
fevers
DISEASE
and night sweats. The
diarrhea
DISEASE
worsened andinstead of having it on and off it became constant. The
fevers
DISEASE
also continued to worsen and peaked at a temp of 103.6 todaythe morning of his admission. Two days prior to admission hestarted noticing
shortness of breath
DISEASE
with simple tasks such sclimbing a few stairs at home. He also describes anon-productive
dry cough
DISEASE
and some chest Admission Date: [**2130-4-6**] Discharge Date: [**2130-4-13**]Date of Birth: [**2054-8-29**] Sex: MService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2777**]Chief Complaint:Acute ParalysisMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:75yo Korean gentleman awoke this morning talked to the bathroomand felt sudden
onset back and abdominal pain
DISEASE
after which helost functioning of bilateral lower extremeties. Taken to OSHwhere abdominal CT scan thought to show dissection of thoracicAAA Pt xferred to [**Hospital1 18**] for possible surgicalintervention but on review of outside CT no
aneurismal rupture
DISEASE
noted.Past Medical History:GERD
HTN
DISEASE
Social History:Previously heavy smoker quit 1.5 yrs ago.no alcoholFamily History:non contributaryPhysical Exam:VS: afeb 130/60 72General: WNWD NADHEENT: Anicteric MMM without lesions OP clearNeck: Supple no LAD no
carotid bruits
DISEASE
no
thyromegaly
DISEASE
CV: RRR s1s2 no m/r/gResp: CTAB no r/w/rAbd: Soft/distendedExt: No c/c/e distal pulses intactSkin: No rashes
petechiae
DISEASE
MS: A&O x 3 interactive appropriate following all commandsSpeech fluent w/o paraphasic errors [** **] Date: [**2123-1-12**] Discharge Date: [**2123-1-19**]Date of Birth: [**2048-3-13**] Sex: FService: MEDICINE
Allergies
DISEASE
:Penicillins / DesmopressinAttending:[**First Name3 (LF) 2291**]Chief Complaint:
hyponatremia
DISEASE
Major Surgical or Invasive Procedure:endoscopy - EGD with EUS [**First Name3 (LF) 2792**]History of Present Illness:74F the patient w/ hx of PE hyponatremia breast CA
HTN
DISEASE
statesthat she was sent in by her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **].The patient has a colonscopy on Wednesday (today) to evaluatefor a possible cause of the patient's stool
incontinence
DISEASE
.Otherwise the patient does state that she has been drinking abit more fluids for upcoming [**Last Name (Titles) 2792**] (but stopped after PCPcoverage told her to come into the hospital and has not takenthe bowel prep yet). Otherwise the patient is not having any
chest pain
DISEASE
or
shortness of breath
DISEASE
. The patient is not having anysymptoms that are new or acute. Pt has persistent stool
incontinence
DISEASE
. The patient notes that she has had 6 BMs in thepast 24 hrs and usually has a number of loose BMs per day. NoCP SOB
palpitations cramps joint pain
DISEASE
. No
headaches
DISEASE
..In the ED inital vitals were 96.7 76 128/58 20 94%No symptoms. Nothing remarkable on exam. Patient's Na decreasedfrom 119 --Admission Date: [**2193-5-30**] Discharge Date: [**2193-5-31**]Date of Birth: [**2151-9-14**] Sex: MService: MEDHISTORY OF PRESENT ILLNESS: The patient is a 41-year-oldmale with a longstanding history of
seizure disorder
DISEASE
andmental retardation who presented to the Emergency Room with apossible
asthma
DISEASE
exacerbation as well as some right armshaking. The patient has a longstanding
seizure disorder
DISEASE
byreport both GTC and complex partial. The patient's
seizures
DISEASE
have been relatively well controlled for the past year up toa few weeks ago. The patient did have an episode ofunresponsiveness thought to be a postictal state. He wasrecently admitted on [**2193-5-24**] at [**Hospital6 649**] for
asthma
DISEASE
exacerbation. He was seen byNeurology at that time for questioned
seizure
DISEASE
activity. HisKeppra was increased during that hospitalization from 5000b.i.d. to 2000 b.i.d.On the morning of admission the patient was found by EMS tohave an O2 saturation in the 80s and appeared
apneic
DISEASE
. It wasfelt that he again was having an
asthmatic exacerbation
DISEASE
. Hewas intubated in the field and brought to [**Hospital3 **][**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **]. At [**Hospital6 2018**] he was noted to have some right arm shaking whichwas felt to be a
seizure
DISEASE
episode. He received 8 mg of Ativanand was placed on propofol. He was also noted to have someteeth chattering.PAST MEDICAL HISTORY: Seizure disorder.
Anoxic
DISEASE
brain injury.Asthma.
Depression
DISEASE
.Fetal alcohol syndrome.Cervical
fracture
DISEASE
.FAMILY HISTORY: No
seizure disorders
DISEASE
.SOCIAL HISTORY: Lives in group home with 24 hoursupervision. No smoking or drinking history.MEDICATIONS ON ADMISSION:1. Depakote 500 mg p.o. t.i.d.2. Keppra 2000 mg p.o. b.i.d.3. Valium 5 mg p.o. b.i.d.4. Neurontin 800 mg t.i.d.5. Celexa 40 mg p.o. q d.6. Albuterol nebulizer.7. Colace 100 mg p.o. b.i.d.8. Pseudoephedrine 30 mg p.o. q.i.d.ALLERGIES: Phenobarbital phenytoin penicillin Haldol.PHYSICAL EXAMINATION: Vital signs: Temperature 100.0 heartrate 76 blood pressure 132/77 saturation of 100 percent onvent assist control/650/20/5 on 85 percent notoverbreathing PIP-31. General: Intubated sedated maleappearing slightly rigid. HEENT: Pupils were 2 cm minimallyreactive to light. Lungs: Expiratory wheezes bilaterally.Cardiovascular: Regular rate and rhythm. No murmurs rubs orgallops. Abdomen: Soft nontender nondistended normoactivebowel sounds. Extremities: No
cyanosis clubbing
DISEASE
or
edema
DISEASE
2Admission Date: [**2179-7-22**] Discharge Date: [**2179-7-24**]Date of Birth: [**2128-5-8**] Sex: MService: CCUHISTORY OF PRESENT ILLNESS: The patient is a 51 year oldmale with no significant past medical history other than
hypertriglyceridemia
DISEASE
low HDL and tobacco abuse who presentswith ST elevation
myocardial infarction
DISEASE
.The morning of admission he woke up at 6:15 a.m. and feltunwell with mild upper chest discomfort at rest. He had no
dyspnea
DISEASE
on exertion nor
shortness of breath
DISEASE
. He went towork had continued discomfort and at noon developed frankupper
chest pain
DISEASE
with radiation to both arms mild
dyspnea
DISEASE
though no
nausea vomiting
DISEASE
or
diaphoresis
DISEASE
.He was brought to the [**Hospital1 69**]where electrocardiogram showed inferior ST segment elevationand he was transferred emergently to cardiac catheterization.He was enrolled in the Cool
Myocardial infarction
DISEASE
Study andrandomized to the cooling arm.Left heart catheterization showed discrete 100% lesion at theright coronary artery with timi one flow. Percutaneoustransluminal coronary angioplasty was performed and 3.5 by 13millimeter stent was employed following which repeatpercutaneous transluminal coronary angioplasty was performed.Repeat angiography showed residual stenosis proximal to thestent. Therefore repeat percutaneous transluminal coronaryangioplasty was done and repeat angiography done showedcomplete resolution of the lesion. He also had a 70% lesionat the second obtuse marginal that was not treated. Leftventriculogram showed
inferior hypokinesis
DISEASE
and ejectionfraction of 42% normal aortic and mitral valves. The rightheart catheterization showed mean right atrial pressure of16 pulmonary artery pressure of 49/25 and a mean pulmonarycapillary wedge pressure of 15. The patient was transientlybradycardic and Atropine was given with good results. He wasadmitted to the CCU in order to continue the cool myocardial
infarction
DISEASE
protocol.PAST MEDICAL HISTORY:1. Hypercholesterolemia. In [**2179-2-9**] total cholesterolwas 238
triglycerides 728
DISEASE
LDL 118 and HDL 29.2. Primary care physician is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 2809**] [**Telephone/Fax (1) 2810**].MEDICATIONS ON ADMISSION: None.ALLERGIES: No known
drug allergies
DISEASE
.SOCIAL HISTORY: The patient is a former EMT. He smokes onehalf pack per day approximately thirty pack year history.No alcohol.FAMILY HISTORY: The patient's father and many in hisfather's family have
coronary artery disease
DISEASE
but no report ofearly
death
DISEASE
.PHYSICAL EXAMINATION: On admission temperature is 34.6(cooling was in place) heart rate 87 blood pressure 106/56respiratory rate 15 oxygen saturation 97%. In general hewas alert in no acute distress. Head eyes ears nose andthroat - The pupils are equal round and reactive to lightand accommodation.
Extraocular movements
DISEASE
are intact.
Sclerae
DISEASE
anicteric. The neck is supple with no
lymphadenopathy
DISEASE
. Jugular venous pressure is not visible.Chest is clear to auscultation anteriorly. Cardiovascular isregular rate and rhythm no murmurs rubs or gallops. NormalS1 and S2 no S3 no S4. The abdomen is soft nontendernondistended positive bowel sounds. Groin sheaths in placeno
hematoma
DISEASE
noted no bruit. Extremities no
cyanosis
DISEASE
clubbing
DISEASE
or
edema
DISEASE
2Admission Date: [**2125-8-31**] Discharge Date: [**2125-9-5**]Date of Birth: [**2052-4-11**] Sex: FService: MEDICINE
Allergies
DISEASE
:Codeine / Oxycodone/Acetaminophen / Morphine SulfateAttending:[**First Name3 (LF) 898**]Chief Complaint:
dyspnea fatigue
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Ms. [**Known lastname 2816**] is a 73 year old female s/p liver [**Known lastname **] forcryptogenic
cirrhosis
DISEASE
in [**2121**] complicated by post-[**Year (4 digits) **]
lymphoproliferative disease
DISEASE
s/p R-CHOP with [**Doctor First Name **] at present andmoderate
pulmonary fibrosis
DISEASE
admitted for lower extremity
swelling
DISEASE
increased work of breathing and generalized
weakness
DISEASE
..In the ED she was noted to have a equivocal UA though deniedurinary frequency or
dysuria
DISEASE
though she did report an episode of
urinary incontinence
DISEASE
. She had a CXR that showed possible RLL
Pneumonia
DISEASE
. She was given Vancomycin and Levaquin for
UTI
DISEASE
andPNA. She was noted to have a BP of 94/66 and HR of 140 thatimproved to 120 with fluids..On review of systems patient reports increased leg
swelling
DISEASE
anddifficulty. Patient unable to state ifthere is a difference inher oxygen tolerance. No SOB at rest. No change in 3 pillow
orthopnea
DISEASE
no PND.Past Medical History:
Interstitial pulmonary fibrosis
DISEASE
home oxygen dependent 2-2.5L NCS/p Liver [**Doctor First Name **] [**4-26**] for cryptogenic
cirrhosis
DISEASE
Post-[**Month/Year (2) **]
lymphoproliferative disorder
DISEASE
s/p CHOP andrituximabType 2 DM
HTN
DISEASE
Hypothyroidism
DISEASE
Social History:Married previously lived at home but recently discharged torehab. Denies tobacco use.Family History:There is no family history of
premature coronary artery disease
DISEASE
or
sudden death
DISEASE
.
Afib
DISEASE
in sisterPhysical Exam:VS: T 96.7 HR 121 BP 135/65 RR 27 91% on 4LNCGen: chronically ill appearing obese famaleHEENT: facial hair tachypneic unable to speak in fullsentencesCV: Tachycardic regular no m/r/gPulm: crackles diffusely no wheezesAbd: obese soft NT ND bowel sounds presentExt: trace
peripheral edema
DISEASE
b/lNeuro: CNs [**2-6**] intact moving all extremitiesPertinent Results:Imaging:[**2125-8-31**]. CXR.IMPRESSION:Possible superimposed right middle lung field
infection
DISEASE
onbackground of
pulmonary fibrosis
DISEASE
..Chest CT. [**2125-7-10**].IMPRESSION:1. Minimal improvement in moderately severe generalized
interstitial lung disease
DISEASE
. Persistent air trapping. No evidenceof
pulmonary hypertension intrathoracic malignancy
DISEASE
or
infection
DISEASE
.2. Longstanding
pneumobilia
DISEASE
..PFTs [**2125-7-5**].Mechanics: The FVC is markedly reduced. The FEV1 is moderatelyto markedly reduced. The FEV1/FVC ratio is elevated.Flow-Volume Loop: Marked restrictive pattern..Impression:Results are consistent with a restrictive ventilatory defectwhich is confirmed by the markedly reduced
TLC
DISEASE
measured on[**2125-3-21**]. Compared to the prior study of [**2125-5-17**] there hasbeen no significant change..Echo [**2125-3-9**].The left atrium is mildly dilated. Left ventricular wallthicknesses are normal. The left ventricular cavity size isnormal. There is no
ventricular septal defect
DISEASE
. The rightventricular cavity is markedly dilated with
depressed
DISEASE
free wallcontractility. The ascending aorta is moderately dilated. Thereare focal
calcifications
DISEASE
in the aortic arch. The aortic valveleaflets (3) are mildly thickened but
aortic stenosis
DISEASE
is notpresent. The mitral valve leaflets are mildly thickened. Thereis no
mitral valve prolapse
DISEASE
. The tricuspid valve leaflets aremildly thickened. There is moderate
pulmonary artery systolic
DISEASE
hypertension
DISEASE
. The main pulmonary artery is dilated. The branchpulmonary arteries are dilated. There is no pericardialeffusion.Compared with the findings of the prior study (images reviewed)of [**2125-1-22**] the right ventricle is markedly dilated..Admit labs137 Admission Date: [**2125-12-10**] Discharge Date: [**2125-12-25**]Date of Birth: [**2052-4-11**] Sex: FService: MEDICINE
Allergies
DISEASE
:Codeine / Oxycodone/Acetaminophen / Morphine SulfateAttending:[**First Name3 (LF) 2817**]Chief Complaint:Hypercarbic
respiratory failure
DISEASE
Major Surgical or Invasive Procedure:Endotracheal intubationPICC line placementHistory of Present Illness:Ms. [**Known lastname 2816**] is a 73 yo female with PMH significant for
ILD
DISEASE
on[**1-27**].5L home O2 diastolic CHF cor pulmonale s/p liver[**Date Range **] on immunosuppression post-[**Date Range **]
myeloproliferative disorder
DISEASE
s/p CHOP and rituximab who wasinitially admitted to hospital after a mechanical fall for
pain
DISEASE
control who is now being transferred to the MICU forhypercarbic/hypoxic
respiratory failure
DISEASE
in the setting of
emesis
DISEASE
. Patient was initially admitted to the medicine serviceon [**12-10**] for a mechanical fall. She stated that prior to herfall she was in her USOH without any change in her baselinerespiratory status or other new symptoms. She stepped on herscale and then lost her balance and landed on her low back. Shewas then brought to [**Hospital1 18**] ED. There was no
head trauma
DISEASE
or LOC byreport. Here spine films revealed no acute fracture. She wasbeing treated with PT and
pain
DISEASE
control. She was not receivingany opiates due to underlying
lung disease
DISEASE
. She did receivedtylenol ibuprofen and lidoderm patch..Yesterday evening the patient triggered after an episode of
nausea
DISEASE
and
vomiting
DISEASE
as well as a drop in her O2 saturation.Changed to face mask with improvement in O2. She remainedhemodynamically stable. No CXR or ABG was performed. Changed to40% ventimask and satting in mid-90s. At 10:30 this am looksashen
cyanotic
DISEASE
and lethargic on 4 L of 50% venti. O2 in high70s at that time. Sleepy but arousable. Increased O2 to 15L on50% ventimask. Given nebs. On exam tight air movement andcracklie but not significantly different from baseline. Initialgas 7.29/97/113 on 15L 50% ventimask. Last ABG in system7.43/47/73 in 3/[**2124**]. Mental status improved with increase inoxygenation. She was given solumedrol 100 mg IV Q8H. Reevaluatedin 1 hr still lethargic but arousable. Repeat ABG 7.28/108/79on 15L 50% ventimask. CXR performed on floor showed somediffuse fluffiness. She received 40 mg IV lasix. She continuesto have
intermittent nausea and vomiting
DISEASE
with 2-3 episodes of
emesis
DISEASE
since yesterday evening..n the MICU she was intubated on [**12-12**] for worsening
hypercarbia
DISEASE
. That evening she spiked a
fever
DISEASE
went into AF vsMAT with HRs into the 160s and
hypotension
DISEASE
to the 80s. She didnot tolerate beta blockers at that time and was started on anamiodarone gtt. She was also started on empiric vancomycin andzosyn for possible aspiration pna. She received aggressivevolume resuscitation and converted to NSR the following morning.Her amiodarone was discontinued given concern for worsening lungand
liver disease
DISEASE
. Her beta blocker was uptitrated. Antibioticswere briefly discontinued on [**12-14**] and restarted on [**12-15**]. Shewas eventually diuresed and was able to be extubated on [**12-16**].She was called out to the medical floor on [**12-17**]..While on the medical floor she was continued on vancomycin andzosyn for presumed aspiration pna. She had no microbiology datato help guide therapy. She was continued on diuretics but hasrun I/O even per documentation. While on floor SBPOs 100s HRs80s RR 20s O2 90s on 3LNC..On the evening of transfer trigger called for increased work ofbreathing. Upon floor evaluation patient denied any subjectiveSOB. O2 requirement the same at 90s n 3LNC and no significantchange in RR. However at Admission Date: [**2115-12-29**] Discharge Date: [**2116-1-29**]Date of Birth: [**2060-12-23**] Sex: FService: SURGERY
Allergies
DISEASE
:Morphine / Oxycodone / Penicillins / Sulfonamides / VancomycinAnd Derivatives / Ibuprofen / Dolobid / Naproxen / ClindamycinHclAttending:[**First Name3 (LF) 148**]Chief Complaint:
Necrotizing Pancreatitis
DISEASE
Cholelithiasis
DISEASE
Major Surgical or Invasive Procedure:OR [**12-30**]: Exploratory laparotomy open cholecystectomyintraoperative cholangiogram common bile duct exploration withcholedochoscopy Pancreatic necrosectomy with wide externaldrainage transgastric feeding jejunostomy.IR [**1-16**]: CT drainage of panc collection w/pigtail placedHistory of Present Illness:55F was admitted to [**Hospital3 417**] with mental status changesand weakness 5 days ago. Of note she has
chronic abdominal pain
DISEASE
form
IBS
DISEASE
and
chronic bony pain
DISEASE
from multiple hips replacementsand
rheumatoid arthritis
DISEASE
. She got a CT today tocomplete her workup which demonstrated severe
necrotizing
DISEASE
pancreatitis
DISEASE
with gas filled abscess. Here she complains of[**11-19**]
abdominal pain
DISEASE
.
Denies
DISEASE
any n/v/d/c/CP/SOB. Per OSH notesher LFTs have all normalized her last INR was 1.6 and her WBCon admission was 20.Past Medical History:
RA IBS GERD
DISEASE
multiple hip replacmentsSocial History:Pt was married for 22 years. Her husband past away recently. Sheis unable to work secondary to
pain
DISEASE
and her
rheumatoid
DISEASE
arthritis
DISEASE
.Family History:Non-contributoryPhysical Exam:PE: 97.4 113 127/69 95%RANAD AOX3no scleral
icterus
DISEASE
no rashesCTABRRRdistended soft diffusely tender mild guarding no reboundno c/c/eguiac negPertinent Results:[**2115-12-30**] 12:10AM BLOOD WBC-31.0*# RBC-4.14* Hgb-12.0# Hct-34.6*#MCV-84 MCH-29.0 MCHC-34.7 RDW-15.5 Plt Ct-298[**2115-12-30**] 12:10AM BLOOD PT-24.1* PTT-35.0 INR(PT)-2.3*[**2115-12-30**] 12:10AM BLOOD Glucose-59* UreaN-11 Creat-0.6 Na-137K-2.8* Cl-99 HCO3-27 AnGap-14[**2115-12-30**] 12:10AM BLOOD Albumin-2.2* Calcium-7.8* Phos-3.5 Mg-2.4Iron-19*[**2115-12-30**] 12:40AM BLOOD Type-ART pO2-96 pCO2-35 pH-7.48*calTCO2-27 Base XS-2[**2115-12-30**] 12:40AM BLOOD Lactate-1.2[**2115-12-30**] 12:10AM BLOOD ALT-20 AST-34 AlkPhos-121* Amylase-183*
TotBili-0.8
DISEASE
[**2115-12-30**] 12:10AM BLOOD Lipase-73*[**2115-12-30**] 10:06PM BLOOD ALT-33 AST-101* LD(LDH)-429* AlkPhos-161*Amylase-131* TotBili-4.7*PATH:Gallbladder choLecystectomy:
Chronic cholecystitis
DISEASE
and
cholelithiasis
DISEASE
.Abd Xray [**12-30**]:IMPRESSION: No foreign object resembling the imaged item isidentified in the radiograph field. Please note that the rightlateral abdomen and the dome of the liver have been excludedfrom the field of view.Chest Xray [**1-1**]:IMPRESSION: AP chest compared to [**12-30**] through 20:Moderate left
pleural effusion
DISEASE
is larger. Small right pleuraleffusionpersists
right basal atelectasis
DISEASE
is improved. Left lung base isobscuredprobably severely
atelectatic
DISEASE
. Heart size is top normal andunchanged.Mediastinal veins slightly engorged. No
pulmonary edema
DISEASE
. No
pneumothorax
DISEASE
.ET tube left subclavian central venous line and nasogastrictube in standard placements.Chest Xray [**1-2**]:No
pneumothorax
DISEASE
. Decrease in left
pleural effusion
DISEASE
. Bibasilarretrocardiac
atelectasis
DISEASE
. No
edema
DISEASE
.Chest Xray [**1-5**]:IMPRESSION: PA and lateral chest compared to [**1-2**]:Left lower lobe consolidation is improving probably resolving
atelectasis
DISEASE
. Small bilateral
pleural effusions
DISEASE
probablyunchanged. Right lung grossly clear. Heart size normal. Leftsubclavian line ends at the junction of the brachiocephalicveins. Skin staples and drains noted in the upper midlineabdomen and right upper quadrant.Chest Xray [**1-15**]:Improvement in left lower lobe retrocardiac atelectasisERCP [**1-13**]:Contrast extravasation from the pancreatic duct.Nonvisualizationof the pancreatic duct within the body and the tail.CT Abdomen [**1-14**]:No extraluminal contrast identified on non-contrast images. Noactive extravasation on arterial or venous phase imaging.Large multiloculated peripancreatic collection with gas andmultiple smaller collections associated with the pancreas. Amedial catheter courses through a portion of the dominantperipancreatic collection. The visualized pancreatic parenchymaenhances normally however due to the close association withthe low-density peripancreatic fluid collection pancreatic
necrosis
DISEASE
cannot be excluded. Attenuation of the splenic veinwhich remains patentCT Guided Drainage [**1-16**]:Successful placement of 8 French pigtail drainage catheter intoleftlateral aspect of peripancreatic collection. Overall decreasedsize of peripancreatic collection compared to two days earlierwith near resolution of the lateral portion following today'sdrainage.CT Abdomen & Pelvis [**1-22**]:Slight decrease in peripancreatic collections since [**2116-1-16**]Brief Hospital Course:Ms. [**Known lastname 2818**] was transferred from an OSH to [**Hospital1 18**] forfurther management of her necrotizing
pancreatitis
DISEASE
. She wasplaced in the SICU and was aggressively resuscitated with IVFand placed on broad spectrum Abx. She was also noted to have amarkedly elevated INR and was reversed with Vitamin K and FFP.She was closely monitored overnight and taken to the OR withDrs. [**First Name (STitle) 2819**] and [**Name5 (PTitle) **] the next morning. She toleratd theprocedure well and taken back to the SICU postoperatively.She remained intubated and sedated and on pressors. She came offher pressors on POD 2 and was extubated on POD 3. She remainedin the SICU until POD 4 when she was transferrred to the floor.-CVS: Pt rate and rhythm monitored on telemetry. She has beenpersistently tachycardic in sinus rhythm controlled with betablockade which she will continue on discharge to rehab.-RESP: Incentive spirometry encouraged during hospital stay.-GI: OR for pancreatic debridement as above nutrition providedvia J-tube and PO as described below. Post-op
constipation
DISEASE
treated with
aggressive bowel
DISEASE
regimen which she will continueas an outpatient. CDiff toxin was negative on [**1-6**] and [**1-20**]-GU: Foley catheter was removed [**1-9**] and pt was able to voidwithout difficulty. Urine cultures were negative [**12-30**] and [**1-14**].-NEURO:
Pain
DISEASE
was controlled on the floor with a dilaudid PCAand when pt started taking PO changed to PO dilaudid.-ACTIVITY: Pt worked with Physical Therapy on the floor. Shedid have
pain
DISEASE
with activity secondary to her
Rheumatoid
DISEASE
Arthritis
DISEASE
but was able to walk with assistance.-F/E/N: Electrolytes were monitored and repleted regularly. Ptmaintained on tube feeds while recovering from surgery. Dietwas advanced slowly as tolerated and tube feed were stopped whenpt was taking adequate PO.-ID: Pt was treated with empiric antibiotics post-operativelyuntil culture and sensitivity data was available. Her positivecultures were: Pan-sensitive E.Coli from OR culture of
pancreatic abscess
DISEASE
on [**12-30**] MRSA from IR culture of pancreaticabscess on [**1-16**] MRSA on culture from biliary drain on [**1-21**].Antibiotic therapy during her hospital stay was as follows:Fluconazole ([**Date range (1) 2820**])Admission Date: [**2151-2-21**] Discharge Date: [**2151-3-19**]Date of Birth: [**2084-2-28**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1283**]Chief Complaint:
chest pain
DISEASE
Major Surgical or Invasive Procedure:[**2-23**] Redo sternotomy CABG x 2 MVRepair (#26 annuloplasty band)History of Present Illness:66 yo M admitted preoperatively.Past Medical History:CAD s/p CABGx2 [**2124**] PPM multiple PCI
NIDDM
DISEASE
GERD s/p dilationof
esophageal stricture
DISEASE
proxysmal A.fib
HTN
DISEASE
Social History:retired communications technicianPhysical Exam:NADAdmission exam unremarkableBrief Hospital Course:Mr. [**Known lastname 2487**] was admitted on [**2151-2-21**]. He remained on heparin andnitroglycerin until he was taken to the operating room on[**2151-2-23**] where he underwent a redo sternotomy CABG x 2 and MVrepair. He was transferred to the SICU in critical but stablecondition on propofol insulin epinephrine levophedmilrinone vasopressin. He was seen by electrophysiology for hispermenant pacer as well as for
atrial fibrillation
DISEASE
with pressordependency. He was started on amiodarone. His IABP was removedon POD #2. He was started on heparin for a fib. He was startedon tube feeds. He was seen by
heart failure
DISEASE
who recommendedTEE/cardioversion and he was cardioverted successfully but hereverted to a fib. He remained in the ICU on inotropes andpressors for many days. They were slowly weaned off with stablehemodynamics. Bilateral chest tubes were placed for largeeffusions. On [**3-6**] he was extubated. His milrinone was weanedto off. On [**3-11**] he was seen by vascular surgery for R flank and
RLQ pain
DISEASE
with a hematacrit and BP drop
retroperitoneal bleed
DISEASE
was found on CT scan his heparin was stopped and he wastransfused. His creatinine rose to 3.0 after the
bleed
DISEASE
andstabilized at 1.6. Anticoagulation was stopped and hishematocrit stabilized without further intervention.He was transferred to the floor on POD #20. His creatinine roseto 1.6 but has remained there. His Lasix was decreased due tohis creatinine. He'd had a persistent small right apical
pneumothorax
DISEASE
which was unchanged with his pleural chest tube onsuction water seal or clamped. It was therefore removed andhis post-removal chest x-ray showed no change. Hishemodynamics and respiratory status have remained stable hisoxygen saturation on room air is 94-95% and he is ready to bedischarged home today.Medications on Admission:lisinopril asa zocor reglan protonix toprol actosglucotrol plavixDischarge Medications:1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2times a day).2. Aspirin 81 mg Tablet Delayed Release (E.C.) Sig: One (1)Tablet Delayed Release (E.C.) PO DAILY (Daily).3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).Disp:*30 Tablet(s)* Refills:*2*4. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2times a day).Disp:*120 Tablet(s)* Refills:*2*5. Pantoprazole 40 mg Tablet Delayed Release (E.C.) Sig: One(1) Tablet Delayed Release (E.C.) PO Q24H (every 24 hours).Disp:*30 Tablet Delayed Release (E.C.)(s)* Refills:*2*6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 timesa day) for 6 days: then 200 mg daily until discontinued by Dr.[**Last Name (STitle) 1295**].Disp:*40 Tablet(s)* Refills:*0*7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) TabletPO Q6H (every 6 hours) as needed for
pain
DISEASE
.Disp:*30 Tablet(s)* Refills:*0*8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY(Daily).Disp:*30 Tablet(s)* Refills:*2*9. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY(Daily).Disp:*60 Tablet(s)* Refills:*2*10. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2times a day).Disp:*60 Tablet(s)* Refills:*2*11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY(Daily).Disp:*30 Tablet(s)* Refills:*2*12. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)Units Subcutaneous at bedtime.Disp:*1 vial* Refills:*2*13. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directedUnits Subcutaneous once a day.Disp:*1 vial* Refills:*2*14. Insulin syringes1/2 cc syringesDispense # 100 with 2 refills prnDischarge Disposition:Home With ServiceFacility:VNA of [**Hospital1 **]Discharge Diagnosis:CADMI [**2124**]CABG x 2 [**2124**]A fib
HTN
DISEASE
NIDDM
DISEASE
GERD
DISEASE
Esophageal dilationMult PCIDischarge Condition:Good.Discharge Instructions:Call with
fever redness
DISEASE
or drainage from incision or weightgain more than 2 pounds in one day or five in one week.Shower no baths no lotions creams or powders to incisions.No lifting more than 10 pounds or driving until follow up withsurgeon.[**Last Name (NamePattern4) 2138**]p Instructions:Dr. [**Last Name (STitle) 1295**] next weekDr. [**Last Name (Prefixes) **] 2 weeksDr. [**Last Name (STitle) 931**] 2 weeksCompleted by:[**2151-3-19**]Admission Date: [**2151-3-21**] Discharge Date: [**2151-3-29**]Date of Birth: [**2084-2-28**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1283**]Chief Complaint:Left rib pain/LUQ
pain
DISEASE
Major Surgical or Invasive Procedure:[**3-21**] Left Thoracentesis[**3-22**] Left Chest tube insertionHistory of Present Illness:67 yo M s/p
CABG/MVR
DISEASE
[**2-23**] with complicated post op course dc'dhome3/16 returned to [**Location **] [**3-21**] c/o LUQ/chest
pain
DISEASE
. Also c/o someSOB secondary to
pain
DISEASE
.Past Medical History:CAD s/p CABGx2 [**2124**] PPM multiple PCI
NIDDM GERD
DISEASE
s/p dilationof
esophageal stricture
DISEASE
proxysmal A.fib
HTN
DISEASE
Social History:retired communications technicianFamily History:NCPhysical Exam:98.0 [**Telephone/Fax (1) 2488**] 16NADLungs with
decreased breath sounds bilaterally with crackles at
DISEASE
both basesCV RRRSternum C/D/IAbd benignExtrem without
edema
DISEASE
Pain
DISEASE
to palpation at left rib cagePertinent Results:[**2151-3-29**] 07:10AM BLOOD WBC-4.7 RBC-3.39* Hgb-9.5* Hct-29.9*MCV-88 MCH-27.9 MCHC-31.7 RDW-14.6 Plt Ct-183[**2151-3-29**] 07:10AM BLOOD Plt Ct-183[**2151-3-25**] 02:54AM BLOOD PT-14.0* PTT-37.3* INR(PT)-1.2*[**2151-3-29**] 07:10AM BLOOD Glucose-126* UreaN-23* Creat-1.3* Na-136K-4.1 Cl-104 HCO3-26 AnGap-10[**2151-3-27**] 05:45AM BLOOD Glucose-112* UreaN-32* Creat-1.5* Na-136K-3.6 Cl-99 HCO3-29 AnGap-12[**2151-3-26**] 04:45AM BLOOD UreaN-46* Creat-1.6* K-3.8[**2151-3-25**] 02:54AM BLOOD Creat-2.0* Na-131* K-4.1 Cl-96 HCO3-27AnGap-12Brief Hospital Course:Mr. [**Known lastname 2487**] was admitted to Cardiac surgery. Interventionalpulmonology performed a left thoracentesis for 750 ccserosanguinous fluid.Thoracic surgery was consulted andrecommended a left chest tube and TPA which was performed.Pleural fluid cultures showed MSSA for which he was placed onnafcillin.
Infectious diseases
DISEASE
recommended 6 weeks of Nafcillin.CT scan on [**3-26**] showed imporved effusion and VATS was cancelled.Chest tube was dc'd without incident on [**3-27**]. CXR on [**3-29**] showedno increase in the effusions and he was ready for discharge on[**2151-3-29**].Discharge Medications:1. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) gramsIntravenous Q6H (every 6 hours).Disp:*240 grams* Refills:*2*2. Aspirin 81 mg Tablet Chewable Sig: One (1) Tablet ChewablePO DAILY (Daily).Disp:*30 Tablet Chewable(s)* Refills:*0*3. Pantoprazole 40 mg Tablet Delayed Release (E.C.) Sig: One(1) Tablet Delayed Release (E.C.) PO Q24H (every 24 hours).Disp:*30 Tablet Delayed Release (E.C.)(s)* Refills:*0*4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2times a day).Disp:*60 Capsule(s)* Refills:*0*5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY(Daily).Disp:*30 Tablet(s)* Refills:*0*6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 timesa day). Tablet(s)7. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO BID (2 timesa day).8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times aday).9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)as needed.Disp:*40 Tablet(s)* Refills:*0*10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hrSig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).Disp:*30 Tablet Sustained Release 24
hr(s
DISEASE
)* Refills:*0*11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:Until dc'd by Dr. [**Last Name (STitle) 1295**].12. Lantus Subcutaneous13. Outpatient Lab WorkWeekly CBC Bun/Creatinine LFTs while on NafcillinResults to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 432**]14. Heparin Lock Flush 100 unit/mL Solution Sig: PICC flush perprotocol Intravenous DAILY (Daily) as needed.Disp:*1 vial* Refills:*2*Discharge Disposition:Home With ServiceFacility:[**Hospital1 **] VNADischarge Diagnosis:Left
pleural effusion
DISEASE
s/p Redo sternotomy CABG x 2 MVRepair [**2151-2-23**]PMH:CAD s/p CABGx2 [**2124**] PPM multiple PCI
NIDDM
DISEASE
GERD s/p dilationof
esophageal stricture
DISEASE
proxysmal A.fib
HTN
DISEASE
HLDDischarge Condition:Good.Discharge Instructions:Call with
fever redness
DISEASE
or drainage from incision or weightgain more than 2 pounds in one day or five in one week.No lifting more than 10 pounds for 10 weeks from surgery.No driving while taking narcotic
pain
DISEASE
medicine.[**Last Name (NamePattern4) 2138**]p Instructions:Dr. [**Last Name (STitle) 1295**] as prior to admissionDr. [**Last Name (Prefixes) **] in 2 weeks[**Hospital **] clinic with nurse practitioner ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2489**] ifpossible)[**Telephone/Fax (1) 2490**]Dr. [**Last Name (STitle) 931**] in [**4-9**] weeks
DR
DISEASE
. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (
Infectious Disease
DISEASE
) Phone:[**Telephone/Fax (1) 457**]Date/Time:[**2151-5-3**] 9:00Completed by:[**2151-3-30**]Admission Date: [**2148-11-29**] Discharge Date: [**2148-12-15**]Date of Birth: [**2085-2-10**] Sex: MService: SURGERY
Allergies
DISEASE
:Codeine / Narcotic Analgesic & Non-Salicylate Comb /AnalgesicsNarcotics Classifier / Ciprofloxacin Er / HeparinAgentsAttending:[**First Name3 (LF) 695**]Chief Complaint:Leak around bilateral PTC drainsMajor Surgical or Invasive Procedure:[**2148-11-29**] CBD resection hepaticojejunostomy ccy liver biopsy[**2148-12-11**] Segment 2 left hepatic artery pseudoaneurysm coilingHistory of Present Illness:Per Dr.[**Name (NI) 1369**] note: The patient is a 63-year-old male with ahistory of
lymphoma
DISEASE
diagnosed in [**2122**] for which he receivedradiation therapy and CHOP. He developed
paralysis
DISEASE
of the leftleg due to radiation in [**2124**] and has been dependent on a braceand crutches. He developed radiation
colitis
DISEASE
with periodicrectal
bleeding
DISEASE
and
incontinence
DISEASE
of stool and urine in [**2127**]. Hedeveloped recurrent
lymphoma
DISEASE
in the porta hepatis and wastreated with radiation therapy in [**2144-9-16**]. He also receivedCHOP and RICE. He developed a
biliary stricture
DISEASE
and common
hepatic duct obstruction
DISEASE
and underwent ERCP and stent placementin [**2144-8-17**] and [**2145-6-17**]. Those stents were removed. In[**2148-1-18**] he presented with
fever
DISEASE
and elevated LFTs. He hadan ERCP at that time and was subsequently referred to [**Hospital1 18**]where he underwent an ERCP on [**2-8**]. This demonstrated thepresence of an existing plastic stent that was blocked withsludge and was removed. He had
small stone
DISEASE
fragments and pusthat were seen extruding from the common duct once the stent wasremoved. There was a long benign-appearing
stricture
DISEASE
of thecommon bile duct and common hepatic duct with dilatation of theintrahepatic ducts proximally. Cytology was negative. Sincethen he has undergone several follow-up ERCPs and dilatation.He has also undergone repeated brushings for cytology that haveall been benign..Because of recurrent
stricture
DISEASE
that has been unresponsive toendoscopic dilatation he was referred for consideration ofRoux-en-Y hepaticojejunostomy. We have discussed the indicationsfor surgical repair the surgical procedure itself riskspotential complications postoperative recovery follow-up andoutcomes. The patient has provided informed consent and isbrought to the operating room for cholecystectomy common bileduct excision and Roux-en-Y hepaticojejunostomy.Past Medical History:1) Left leg
paralysis
DISEASE
from radiation to pelvic fossa in [**2122**]2)
atrial fibrillation
DISEASE
3) histiocytic-lymphocytic lymphoma s/p CHOP and XRT4) large B-cell lymphoma to porta hepatis s/p XRT CHOP andcyclophosphamide ([**2143**]) now without evidence of disease5) gastritis6) history of HCV with reportedly unremarkable liver biopsythough pt remarks that he was told he has early signs of
cirrhosis
DISEASE
- will attempt to get outside records7) status post left leg
fracture
DISEASE
.8) bilateral inguinal
hernia
DISEASE
repair9) gastritis10)VRE
bacteremia
DISEASE
[**2148-11-13**]11)[**2148-11-29**] Common bile duct excision Roux-en-Yhepaticojejunostomy cholecystectomy segment IVB massresection intraoperative ultrasoundSocial History:His social history is significant for the fact that he ismarried and is currently employed as a psychologist. He iscurrently retiring from his practice due to health reasons. Hehas two adult children who are healthy.Family History:His family medical history is significant for his parents whoare both deceased his mother from
hypertension
DISEASE
and father from
congestive heart failure
DISEASE
.Physical Exam:97.6 57 103/49 14 97%RA 6'2Admission Date: [**2143-3-3**] Discharge Date: [**2143-3-18**]Date of Birth: [**2116-6-27**] Sex: FService: ACOVECHIEF COMPLAINT: Fever.HISTORY OF PRESENT ILLNESS: The patient is a 26-year-oldwoman with a history of IV
drug abuse
DISEASE
who initiallypresented to an outside hospital on [**2143-3-2**] from adrug and detoxification facility with a chief
complaint
DISEASE
of
headache abdominal pain
DISEASE
and
fever
DISEASE
. At the outsidehospital the patient was found to be
febrile
DISEASE
to 104.6degrees F and she subsequently developed
hypotension
DISEASE
with asystolic blood pressure in the 80s.During this initial evaluation the patient was confused andonly intermittently answering questions. There was concernfor possible
headache neck stiffness
DISEASE
and
photophobia
DISEASE
sogiven the concern for
meningitis
DISEASE
a spinal tap was done.This study demonstrated 50 white blood cells (84%neutrophils) 10 red blood cells protein of 23 glucose of86 and 0-5 yeast per high power field. Given these findingsand concern for
meningitis
DISEASE
the patient received Vancomycinceftriaxone metronidazole and gentamicin at the outsidehospital. Given the lack of Intensive Care Unit beds at theoutside hospital the patient was therefore transferred tothe [**Hospital1 69**] for furtherevaluation.On arrival to the Emergency Department at the [**Hospital1 346**] the patient was found to have
icteric sclerae a 2/6 systolic ejection murmur abdominal
DISEASE
guarding and
right upper quadrant tenderness
DISEASE
. Given theconcern for an abdominal process the patient was givenlevofloxacin and metronidazoleAdmission Date: [**2118-11-12**] Discharge Date: [**2118-11-16**]Date of Birth: [**2077-11-7**] Sex: MService: NEUROLOGY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2518**]Chief Complaint:left arm
weakness slurred speech
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:41 year old right handed male with history of crack cocaine useprior
strokes
DISEASE
presents with sudden onset left arm weaknessleft nasolabial flattening and
dysarthria
DISEASE
. Pt reports lastsmoking a marijuana and crack cocaine cigarette at 7pm thisevening. At 10:30pm while he was playing pool in a bar henoticed the sudden onset of left arm Admission Date: [**2121-7-25**] Discharge Date: [**2121-8-3**]Date of Birth: [**2077-11-7**] Sex: MService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2534**]Chief Complaint:
HTN
DISEASE
HematemesisMajor Surgical or Invasive Procedure:Exploratory Laparotomy Anterior GastrotomyHistory of Present Illness:The patient is a 43 y/o M with no past history of
GI bleeding
DISEASE
who presented to the ED with an episode of
hematemesis
DISEASE
earlierin the day. Per report the patient had one episode of
emesis
DISEASE
with possible blood in it earlier in the day and called hisPCP's office who instructed him to present to the ED. While inthe ED he had an episode of a large amount of bright red bloody
emesis
DISEASE
..On arrival to the ED the patient's VS were 98.0 86 181/115 16100. Hematocrit was 43. He was given 40 mg IV protonix and thenstarted on a protonix gtt at 8mg/hr. An 18G and a 16G IV wereplaced for access. NG lavage was performed and did not clear. GIwas consulted with plans to see the patient in the ICU. Inaddition the patient was also given zofran for
nausea
DISEASE
. VS priorto transfer were 85 151/107 22 97%..On arrival to the ICU the patient's VS were T: 98.3 BP: 174/116P: 81 R: 21 O2: 99% on
RA
DISEASE
. He denied any current
chest pain
DISEASE
shortness of breath abdominal pain nausea
DISEASE
or lightheadedness.He reported darker than usual stools for the past 2 weeks. Hedid admit to significant alcohol use. He denied any othercomplaints at this time...Review of sytems:(Admission Date: [**2193-6-9**] Discharge Date: [**2193-6-10**]Date of Birth: [**2151-9-14**] Sex: MService: [**Hospital1 139**] FirmHISTORY OF PRESENT ILLNESS: The patient is with mentalretardation
seizure disorder asthma
DISEASE
and recurrentaspiration
pneumonia
DISEASE
who was admitted to the Intensive CareUnit already intubated for
apnea
DISEASE
.On the day of admission the patient was sitting bolt uprightin bed in
respiratory distress
DISEASE
. He was given Albuterol nebwithout improvement. At that time his oxygen saturation was88 percent and he was intubated for
apnea
DISEASE
.An initial chest x-ray showed bilateral lower lobe opacitiesconsistent with aspiration
pneumonia
DISEASE
. He was extubated onthe day after admission.On presentation the patient was
febrile
DISEASE
and started onLevofloxacin and Flagyl for aspiration
pneumonia
DISEASE
. He wascalled out to the floor three days after admission.PAST MEDICAL HISTORY: Seizure disorder secondary to
anoxic
DISEASE
brain injury
DISEASE
. Over the past three months the patient hashad increasing
seizure
DISEASE
activity from baseline according tohis primary caretaker.Mental retardation.Asthma.
Depression
DISEASE
.Fetal alcohol syndrome.Recurrent aspiration
pneumonia
DISEASE
.History of positive PPD.Status post fall in [**2188**] with a C7
fracture
DISEASE
.History of multiple
psychiatric
DISEASE
admissions (The patient canbe combative and assaultive at times).MEDICATIONS ON ADMISSION: Depakote 500 mg p.o. t.i.d.Neurontin 100 mg p.o. t.i.d. Celexa 30 mg p.o. q.d.Albuterol nebs q.6 hours p.r.n. Colace 100 mg p.o. b.i.d.Atrovent Keppra [**2188**] mg p.o. b.i.d. Valium 10 mg p.o.b.i.d. Citalopram.FAMILY HISTORY: No
seizure disorder
DISEASE
.ALLERGIES: Phenobarbital Penicillin Haldol.PHYSICAL EXAMINATION: Vital signs: Upon transfer to theMedical Floor temperature was 97.9 with a T-max of 101pulse 83 ranging from 51-126 blood pressure 110/47respirations 21 ranging from 21-32 oxygen saturation 97percent on 4 L nasal cannula. General: Examination wassignificant for a young black male in no acute distress. Thepatient was awake and responding to voice appropriately.HEENT: Moist mucous membranes. Pupils equal round andreactive to light. Neck: Supple. Cardiovascular: NormalS1 and S2. Regular rate and rhythm. Lungs: Decreasedbreath sounds at the bases with a few audible wheezes.Abdomen: Normoactive bowel sounds. Extremities: No
edema
DISEASE
.LABORATORY DATA: White count 6.4 hematocrit 40.5Admission Date: [**2152-3-16**] Discharge Date: [**2152-3-22**]Date of Birth: [**2073-11-29**] Sex: FService: MEDICINE
Allergies
DISEASE
:GemfibrozilAttending:[**First Name3 (LF) 443**]Chief Complaint:
chest pain
DISEASE
Major Surgical or Invasive Procedure:cardiac catheterizationHistory of Present Illness:Ms. [**Known lastname 931**] is a 78 year-old woman with h/o
HTN
DISEASE
hyperchol
CHF ESRD
DISEASE
(not yet on HD) who was transfered from [**Hospital **] [**Hospital 2538**] for management of NSTEMI..The patient describes 2 types of
pain
DISEASE
. The first
pain
DISEASE
is a Rsternal
pain
DISEASE
that occurs while eating and is usually relievedwith physical massage. She reports having this
pain
DISEASE
for years..The second type of
pain
DISEASE
started 2 days ago but has not recurrednow for more than 24 hours. She reports having epigastric
chest pain
DISEASE
2 days prior to admission that lasted for a wholeday. She also noted
pain
DISEASE
in her R arm at the same time. Deniesassociated
N/V diaphoresis
DISEASE
or sob. No recent change inweight LE
swelling
DISEASE
or PND. Patient did have some mild
cough
DISEASE
with yellow productive sputum but no f/c. She also c/o chroniclightheadedness that she attributes to her medication along withsome
intermittent vertigo
DISEASE
. Patient otherwise denies anymyalgias/arthralgias. She continues to urinate nodysuria/hematuria
intermittent constipation
DISEASE
. She also haschronic
insominia
DISEASE
. Her exercise capacity consists of [**12-14**] ablock limited by
fatigue
DISEASE
. Patient told her daughter about the
pain
DISEASE
who then contact[**Name (NI) **] patient's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2539**]. PCP referredthe patient to [**Hospital1 **] [**Location (un) 620**] ED for evaluation..Upon arrival to the OSH ED labs revealed Cr 2.7Admission Date: [**2152-4-6**] Discharge Date: [**2152-4-11**]Date of Birth: [**2073-11-29**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:GemfibrozilAttending:[**First Name3 (LF) 922**]Chief Complaint:anginaNSTEMIMajor Surgical or Invasive Procedure:cabg x4 [**2152-4-6**] (LIMA to LAD SVG to DIAG SVG to OM 1 and OM2)History of Present Illness:78 yo female with mutiple cardiac risk factors. Recentlyadmiutted for
angina
DISEASE
and ruled in for NSTEMI. Cath revealed LAD70% DIAG 70% OM1 99% CX 70% and small RCA without lesions.PCI was unsuccessful at cath and now referred for CABG.Past Medical History:NSTEMI
CVA
DISEASE
([**8-16**]Admission Date: [**2113-2-10**] Discharge Date: [**2113-2-15**]Date of Birth: [**2036-9-8**] Sex: MService:HISTORY OF PRESENT ILLNESS: This patient came into thehospital originally on [**2113-2-3**] and was referred tocardiac surgery after cardiac catheterization revealed three-
vessel disease
DISEASE
. This 76-year-old gentleman presented to anoutside hospital with
vertigo
DISEASE
. The head CT was negative. Hehad an exercise tolerance test on [**5-6**] that showedanterior akinesis with exercise and was referred into [**Hospital1 **] for cardiac catheterization.PAST MEDICAL HISTORY: Hernia repair x 3.
Nephrolithiasis
DISEASE
.
Osteoarthritis
DISEASE
of the neck and lumbar region.
Hypercholesterolemia
DISEASE
.ORIF of the right ankle.Pilonidal cyst removal.MEDS AT HOME:1. Aspirin on Monday Wednesday and Friday.2. Multivitamin.At [**Hospital1 **] the following medications wereadded:1. Metoprolol 12.5 mg po bid.2. Aspirin 325 mg po qd.3. Colace 100 mg po bid.ALLERGIES: He had no known drug
allergies
DISEASE
.SOCIAL HISTORY: He had a remote tobacco history since hequit 30 years ago. He is married and lives with his wife.[**Name (NI) **] use of alcohol or recreational drugs noted by thepatient.FAMILY HISTORY: Positive family history as his brother hadundergone CABG surgery also.REVIEW OF SYMPTOMS: He had no
chest pain palpitations
DISEASE
edema orthopnea
DISEASE
. No
gastritis peptic ulcer disease
DISEASE
. Noproblems with
nausea vomiting diarrhea
DISEASE
or
constipation
DISEASE
.He had no
melena
DISEASE
or
hematochezia
DISEASE
reported. No history of
peripheral vascular disease claudication diabetes
DISEASE
hypertension
DISEASE
. No symptoms of
CVA
DISEASE
or
TIA
DISEASE
.LABS PREOPERATIVE ON [**2-3**]: White count 8.6 hematocrit41.8 platelet count 158000 PT 13.9 PTT 53.4 INR 1.3sodium 140 K 3.8 chloride 103 CO2 26 BUN 20 creatinine0.8 with a blood sugar of 95 ALT 21 AST 19 alk phos 51total bili 0.5 albumin 3.8. His EKG showed first degree AVblock at 72 beats per minute with a right bundle branchblock and Q waves present in III and F as well as flipped Twaves in
AVL
DISEASE
and V2. Cardiac catheterization showed the leftmain arose from the noncoronary cusp. The LAD had serial 90percent lesions OM1 70-80 percent lesion OM2 70-80 percentlesion RCA proximally 50 percent lesion and distal 80percent lesion and a left posterolateral 80 percent lesionwith an ejection fraction of 50 percent.
EXAM
DISEASE
: The patient was afebrile with a heart rate of 67 insinus rhythm with a blood pressure of 147/86 respirations20 satting 96 percent on room air. He was alert andoriented x 3. NAD. Nonfocal exam. His pupils were equaland reactive to light and accommodation. EOMS were normal.He was anicteric. He had a normal oropharynx. His neck wassupple with no
lymphadenopathy
DISEASE
or
thyromegaly
DISEASE
. No JVD. No
bruits
DISEASE
heard. Lungs were clear bilaterally. Heart wasregular rate and rhythm with S1 and S2 sounds present but nomurmur rub or gallop. His abdomen was soft nontendernondistended with normal bowel sounds. No
hepatosplenomegaly
DISEASE
or masses palpated. Extremities were warm and well-perfusedwith no
clubbing cyanosis edema
DISEASE
or varicosities. Hispulses were as follows: 2 plus bilaterally on the carotidswith no bruits 2 plus bilaterally on femorals 2 plusbilaterally on radials and 2 plus bilaterally on both DP andPT peripheral pulses.ASSESSMENT: The patient did have severe
two-vessel disease
DISEASE
with an anomalous left main. He was referred to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) 2545**] for cardiac surgery with the plan as patient to gohome as asymptomatic and stable and return for surgery.HO[**Last Name (STitle) **] COURSE: The patient was readmitted on [**2113-2-10**] to Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] service and he underwent acoronary artery bypass grafting x 3 with LIMA to the LADvein graft to the posterolateral and a vein graft to the OM.In addition an endarterectomy of the proximal LAD wasperformed with a vein patch angioplasty proximal to the LIMA-LAD anastomosis. The patient was transferred toCardiothoracic ICU in stable condition on Neo-Synephrine dripand a propofol drip.On postoperative day 1 the patient was doing wellpostoperatively and was extubated at 2230 in the evening withgood ABGs and continued to be monitored closely but wasproceeding well. The Neo-Synephrine was weaned onpostoperative day 2. The patient had no events overnight.He had a T-max of 100.3. He was
sinus tachycardia
DISEASE
at 108with a blood pressure of 118/52 and was satting 96 percenton 1 liter nasal cannula. He remained on Neo-Synephrine dripat 1 mcg/kg/min. The patient started aspirin and Plavixboth. He remained in the Cardiothoracic ICU. Postoperativelabs as follows: K 3.9 BUN 20 creatinine 0.8. Hematocritdropped slightly from 26.5 to 21.5. The patient wastransfused 2 units of packed red blood cells. Chest x-raywas repeated and Lasix diuresis was begun. The patientremained in the ICU to manage his dependence on Neo-Synephrine and his dropping hematocrit.On postoperative day 3 his chest tubes had been pulled. Hedid receive the 2 units of packed red blood cells on the dayprior. He was restarted on his beta blocker metoprolol 12.5[**Hospital1 **] in addition to the aspirin and Plavix. He was in sinusrhythm at 90 with a blood pressure of 153/66 with areasonable blood gas and was satting 94 percent on 1 liternasal cannula. Hematocrit remained increased to 25.5 post-transfusion with a BUN of 17 creatinine 0.6. Lasix wasincreased to 20 [**Hospital1 **]. Pacing wires were discontinued. Thepatient was transferred out to the floor where he began hisambulation with physical therapy and the nursing staff andto continue working with them.He did have an episode of increased heart rate to 110.Lopressor was given on the 22 at 1800 in the evening. Thisdropped his heart rate down into the 80's again. He did havea
complaint
DISEASE
of some
tooth pain
DISEASE
on the right side and had alittle bit of
serosanguineous
DISEASE
drainage from the distalportion of his sternal incision. He continued ambulatingtid. Discharge teaching and planning was begun. The
serous
DISEASE
drainage from his chest was managed and he continued withpulmonary toilet and ambulation.On postoperative day 4 the patient still was complaining ofsome
tooth pain
DISEASE
. He continued his ambulation on the floor.He had a heart rate of 88 with a blood pressure of 90/56 andremained in stable condition. BUN 17 creatinine 0.6 fromthe day prior. His lungs were clear bilaterally. Hisabdominal exam was benign. His wounds were clean
dry
DISEASE
andintact. His heart was regular rate and rhythm. The plan wasto try and DC him home if possible after evaluation byphysical therapy. The patient had some issue with
constipation
DISEASE
for which Milk of Magnesia was prescribed.Labs on the 23 were as follows: White count 7.5 hematocrit28.4 BUN 17 creatinine 0.8 blood sugar 123. Magnesium wassupplemented when the lab value returned at 1.8 and wasrepleted. K was 3.7 sodium 140. His heart rate increasedslightly during the day from sinus rhythm to sinus tach withhis known
bundle branch block
DISEASE
. He was seen by casemanagement on the 23. PT evaluated the patient andanticipated that he would be able to go home as soon as hewas medically stable. The plan was to follow-up with CareGroup Home Care and possibly [**Last Name (un) **] for better sugarmanagement.On postoperative day 5 the patient was stablehemodynamically with a blood pressure of 140/67 in sinusrhythm in the 80's satting 96 percent on room air. He didfinally have the bowel movement. He was receiving Ambienalso to help a little bit with sleep. His heart was regularrate and rhythm. He was in no apparent distress. The [**Last Name (un) **]consult was obtained. His lungs were clear. His abdomen wasbenign. It was recommended to the patient that he haveantibiotics pre any dental procedures. [**Last Name (un) **] consult wasdone. Please refer to their note on the 24. The patient wasgiven information about scheduling an appointment as anoutpatient for follow-up as well as educational training forbetter management of his
diabetes
DISEASE
.On the 24 the patient was discharged to home. His exam wasbenign. His labs were as follows: Sodium 140 K 3.7chloride 101 CO2 32 BUN 17 creatinine 0.8 white count 7.5and 28.4. All these labs were previously noted from the daybefore.DISCHARGE MEDICATIONS:1. Metoprolol 25 mg po bid.2. Lasix 20 mg po bid x 7 days.3. KCL 20 mEq po bid x 7 days.4. Colace 100 mg po bid.5. Aspirin 325 mg po qd.6. Percocet 1-2 tabs po prn
pain
DISEASE
q 4-6 h.7. Plavix 75 mg po qd.8. Ambien 5 mg po hs prn.FO[**Last Name (STitle) 996**]P: The patient was advised to come back to the [**Hospital 409**]Clinic on FAR-2 in 1 week for wound check. Follow-up withhis PCP and cardiologist in approximately 1-2 weeks. Makehis appointment with the [**Hospital **] Clinic as he had beendirected to. See Dr. [**Last Name (Prefixes) **] for his postoperative visitin the office at 4 weeks.DISCHARGE DIAGNOSES: Status post coronary artery bypassgrafting x 3.
Coronary artery disease
DISEASE
.
Nephrolithiasis
DISEASE
.
Osteoarthritis
DISEASE
.
Hypercholesterolemia
DISEASE
.Status post
hernia
DISEASE
repair x 3.Status post open reduction and internal fixation rightankle.Status post pilonidal cyst removal.DISCHARGE STATUS: Discharged to home with follow-upinstructions aforementioned on [**2113-2-15**]. [**Doctor Last Name **] [**Last Name (Prefixes) **] M.D. [**MD Number(1) 1288**]Dictated By:[**Last Name (NamePattern1) **]MEDQUIST36D: [**2113-5-10**] 11:23:48T: [**2113-5-10**] 13:30:20Job#: [**Job Number 2547**]Admission Date: [**2180-9-4**] Discharge Date: [**2180-10-20**]Date of Birth: [**2109-8-6**] Sex: MService: CARDIAC CARE UNITHISTORY OF THE PRESENT ILLNESS: The patient is a 71-year-oldmale with a history of biventricular pacer and AICD with
CHF
DISEASE
who had a mechanical fall and bruised his left side.Approximately one week ago he began to develop
fevers
DISEASE
chills
DISEASE
as well as warmth and
erythema
DISEASE
around the area of hispacer pocket. He had a flu shot one day prior and thoughtthat the
fevers
DISEASE
and
chills
DISEASE
were related to that. He went toan outside hospital and was diagnosed with
cellulitis
DISEASE
givenone dose of IV antibiotics and sent home. He was told toreturn to the hospital and was given IV Unasyn. Anultrasound of the area was done. No blood cultures wererecorded. The patient was transferred for medical managementand possible surgical drainage removal of pacer.PAST MEDICAL HISTORY:1. CAD: Two
vessel disease
DISEASE
of
RCA
DISEASE
and mid LAD which werefindings noted on catheterization in [**2171**]. He has 2Admission Date: [**2180-9-4**] Discharge Date: [**2180-10-20**]Date of Birth: [**2109-8-6**] Sex: MService: CARDIAC CARE UNITADDENDUM:RADIOGRAPHIC EXAMINATION: Chest x-ray on [**2180-10-17**]:No
pneumothorax
DISEASE
. Lung fields are clear. Moderate left
ventricular enlargement
DISEASE
.Right upper quadrant ultrasound: The liver has a homogeneousechotexture and contains two small echogenic lesions both ofwhich are in the right lobe. These are compatible with small
hemangioma
DISEASE
. No other focal
liver lesions
DISEASE
. The gallbladderwas mildly distended. No
gallbladder wall edema
DISEASE
no evidenceof
cholelithiasis
DISEASE
. Common bile duct measured 4 mm and waswithin normal limits.Impression: Normal appearing gallbladder given the patient'sfasting state without evidence of
cholelithiasis
DISEASE
small
hemangioma
DISEASE
....................CT of the abdomen and pelvis: Impression: 1. No fluidcollection or abscess identified. 2. Mild thickening of thewall of the ascending colon similar to prior examination.This pattern is persistent since the last CT examination andraises the possibility of
colitis
DISEASE
infectious ischemic orinflammatory.CT of the chest abdomen and pelvis: Impression: 1. Left
pneumothorax
DISEASE
with epicardial pacer wires traversing the leftpleura. This is not the expected course of epicardial pacingwires. 2. Bilateral
pleural effusions
DISEASE
and compressive
atelectasis
DISEASE
in the lung bases. 3. 7 mm nodule in the rightmajor fissure. While this appears to have increased sincethe prior study there may be associated volume averagingfrom the fluid in the fissure. Follow-up study suggested.4. Extended gallbladder. 5. Possible thickening of thececum which is most likely due to circumferential fluid.There is no surrounding fat stranding.Echocardiogram on [**2180-9-11**]: Conclusions: 1. Left atrium ismildly dilated. 2. There is symmetric left ventricular
hypertrophy
DISEASE
. The left ventricular cavity size is normal.Overall left ventricular systolic function is very difficultto assess but is probably moderately
depressed
DISEASE
. Overall leftventricular systolic function cannot be reliably assessed.3. Aortic valve leaflets were mildly thickened. 4. Mitralvalve leaflets were mildly thickened. 5. No pacing wireswere visualized. 6. Compared with the findings of the priorreport of [**2180-9-5**] there is probably no significant change.Ejection fraction 20-25%.Echocardiogram on [**2180-9-5**]: Conclusions: 1. Left atriummildly dilated. The right atrium is mildly dilated. In someviews very small 2 mm highly mobile echodensity seen inclose proximity attached to the atrial lead consistent withpossible
thrombus vegetation
DISEASE
artifact. Left ventricular wallthickness and cavity size normal. There is severe globalleft ventricular hypokinesis with akinesis of the inferiorinferolateral walls. No
left ventricular thrombus
DISEASE
is seen.The right ventricular cavity is dilated. There is moderateglobal right
ventricular free wall hypokinesis
DISEASE
. The aorticvalve leaflets are mildly thickened but not stenotic. Mitralleaflets were mildly thickened. Mild 1Admission Date: [**2104-3-24**] Discharge Date: [**2104-4-4**]Date of Birth: [**2021-6-12**] Sex: FService: EMERGENCY
Allergies
DISEASE
:Levofloxacin / Penicillins / IV Dye Iodine Containing /
Statins-Hmg-Coa
DISEASE
Reductase Inhibitors / simvastatinAttending:[**First Name3 (LF) 2565**]Chief Complaint:red urineMajor Surgical or Invasive Procedure:Urinary Foley catherizationCentral line insertionMechanical IntubationHistory of Present Illness:Mrs. [**Known firstname 2554**] F. [**Known lastname 2555**] is a 82 year-old spanish and italianspeaking woman with
DM2 asthma AFib
DISEASE
who presents with weaknessfor the past week. She has been unable to stand or get out ofbed and has had generalized weakness..In the ED initial vitals were 99 103 181/84 16 96%. Herlabs were significant for CK elevation to [**Numeric Identifier 2566**] without renalfailure. Her EKG was unchanged from prior. Neurology wasconsulted given her
weakness
DISEASE
and felt this was likely related torhabdo. Patient received approximately 1 liter of NS in the ERgiven CXR with concern for
volume overload
DISEASE
. Head CT showed small(Admission Date: [**2164-3-19**] Discharge Date: [**2164-3-27**]Date of Birth: [**2095-10-16**] Sex: MService: NEUROLOGY
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 2569**]Chief Complaint:right superior
cerebellar artery stroke
DISEASE
Major Surgical or Invasive Procedure:Transesophageal echocardiogramUpper gastrointestinal endoscopyHistory of Present Illness:68 RHM with PMH of
HTN
DISEASE
came to the ED for evaluation of acuteonset
vertigo
DISEASE
and
nausea
DISEASE
. Code
stroke
DISEASE
was called.He was walking to the car this pm to go for golf. He was in theparking lot and felt sudden onset
dizziness
DISEASE
. The sensation was
violent
DISEASE
and felt as if the entire Admission Date: [**2164-10-22**] Discharge Date: [**2164-10-30**]Date of Birth: [**2095-10-16**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 165**]Chief Complaint:
Chest pain
DISEASE
Major Surgical or Invasive Procedure:[**2164-10-22**]: Emergency repair of type-A ascending aortic dissectionwith ascending aortic and hemiarch replacement with a size-28Gelweave graft.History of Present Illness:69 year old male woke up this am with acute epigastic
pain
DISEASE
chest pain shortness of breath
DISEASE
and
diaphoresis
DISEASE
. He called EMSand was brought to ED and was found to have type A dissectionand is going emergently to OR with Dr.[**First Name (STitle) **].Past Medical History:
Hyperlipidemia
DISEASE
Hypertension
DISEASE
BPHright superior
cerebellar artery stroke
DISEASE
prostate cancer
DISEASE
s/p brachytherapy 5 years ago
gout
DISEASE
Afib
DISEASE
Past Surgical History:s/p lumbar laminectomys/p tonsillectomySocial History:Lives with wife Ex [**Name (NI) 2570**] quit smoking 25 years ago drinks aglass of wine on occasions no
drug abuse
DISEASE
Family History:
Strokes
DISEASE
in both parentsPhysical Exam:Admission:Pulse:58 Resp:18 O2 sat:97B/P 206/72Height:6'1Admission Date: [**2140-3-5**] Discharge Date: [**2140-3-16**]Service:CHIEF COMPLAINT: Bright red blood per rectum.PAST MEDICAL HISTORY: Aortic stenosis
hypertension
DISEASE
spinal
stenosis hemorrhoids peptic ulcer disease
DISEASE
history of
gastrointestinal bleed
DISEASE
status post laminectomy status postright hip replacement status post salivary calculus removalin the [**2087**].OUTPATIENT MEDICATIONS: Zantac 150 mg p.o. b.i.d.Admission Date: [**2140-4-20**] Discharge Date: [**2140-4-21**]Service: MICUHISTORY OF THE PRESENT ILLNESS: The patient is an88-year-old gentleman with severe
aortic stenosis peptic
DISEASE
ulcer disease
DISEASE
hypertension
DISEASE
who presented to the ED with
fevers
DISEASE
and
hypotension
DISEASE
to the 80/50 blood pressure.Responded well to IV fluids while in the ED but denied any
chest pain abdominal pain
DISEASE
or any urinary symptoms.PAST MEDICAL HISTORY:1. Peripheral
vascular disease
DISEASE
.2. Aortic stenosis.3. Colonic polyps.4. Anemia.5.
Hypertension
DISEASE
.6. Total hip replacement of the right side.7. BPH.8. Chronic
renal insufficiency
DISEASE
.9. Spinal stenosis.ALLERGIES: The patient is
allergic
DISEASE
to penicillinerythromycin Ultram.ADMISSION MEDICATIONS:1. Ambien.2. Clindamycin.3. Desipramine.4. Lasix.5. Lactulose.6. Lisinopril.7. Ativan.8. MS Contin.The patient became progressively more listless and somnolentin the ED and pressure continued to drop. He responded tomore fluids and also required nasal cannula 100% 02.PHYSICAL EXAMINATION ON ADMISSION: Initially the patienthad a temperature of 99.2 heart rate 112 blood pressure95/60 respiratory rate 24 saturating 100% on nasal cannula.General: The patient was an elderly man in no apparentdistress awaking to voice. HEENT: The oropharynx was clear.The mucous membranes were
dry
DISEASE
. The pupils were equally roundand reactive to light. Lungs: Clear anteriorly. Heart:Tachycardiac. There was a III/VI
systolic ejection murmur
DISEASE
.Abdomen: Soft nontender nondistended. Extremities: No
endocarditis
DISEASE
stigmata noted.LABORATORY DATA: WBC of 10.3 with 46 bands 35.1 hematocritcreatinine 2.0. Sodium 124 chloride 87. The U/A hadgreater than 50 WBCs with many bacteria.The chest x-ray had a right
pleural effusion
DISEASE
that was olddecreasing in size compared to previous.The EKG had no acute ST-T wave changes tachy appeared to be
LVH
DISEASE
.HOSPITAL COURSE: INFECTION: Likely his
hypotension
DISEASE
was dueto
sepsis
DISEASE
secondary to
UTI
DISEASE
. The patient also stated that hehad some instrumentation done of his heart which could alsoaccount for his
septic
DISEASE
picture. The patient was started onempiric antibiotics. Blood cultures were also obtained. IVfluids were given. The patient had antibiotics of Levaquinand clindamycin. The patient is a DNR/DNI status.HYPONATREMIA: Appears to be
hypovolemic
DISEASE
. We will place withnormal saline. On presentation to the ICU the patient wasalready in agonal respirations.Shortly thereafter I was called to the room. The patientwas
asystolic
DISEASE
and the patient was not responsive to verbal
pain
DISEASE
or tactile stimuli. No heart sounds were heard. Pupilswere midline dilated not reactive. There was a lack ofbreath sounds.The immediate cause of
death
DISEASE
was likely
cardiac arrest
DISEASE
.Secondary cause
sepsis
DISEASE
. [**Name6 (MD) **] [**Name8 (MD) **] M.D. [**MD Number(1) 968**]Dictated By:[**Last Name (NamePattern1) 2584**]MEDQUIST36D: [**2140-6-9**] 04:23T: [**2140-6-12**] 16:16JOB#: [**Job Number 2585**]Admission Date: [**2180-10-29**] Discharge Date: [**2180-11-7**]Date of Birth: [**2128-4-5**] Sex: FService: MEDICINE
Allergies
DISEASE
:IodidesAttending:[**First Name3 (LF) 2024**]Chief Complaint:
Dyspnea
DISEASE
Major Surgical or Invasive Procedure:
pericardiocentesis
DISEASE
History of Present Illness:52 year old woman with a PMH significant for metastatic
breast
cancer
DISEASE
with lung and brain
mets
DISEASE
admitted to the [**Hospital Unit Name 153**] formanagement of
respiratory distress
DISEASE
. The patient reports thatshe has had progressively worsening
dyspnea
DISEASE
on exertion and a
cough
DISEASE
productive of whitish sputum over the past several monthsand that these symptoms prompted her CT chest in [**8-4**] thatdemonstrated her
pulmonary metastasis
DISEASE
. She states that over thepast 2 days she has had worsening
shortness of breath
DISEASE
such thatshe is now unable to climb [**11-27**] flight of stairs. She alsoendorses some right sided
chest pain
DISEASE
that is not pleuriticwhich she states has been intermitent for several months. Shedenies any f/c/s palpitaitons n/v/d sore
throat LBP
DISEASE
or
myalgias
DISEASE
..In the [**Hospital1 18**] ED initial VS 97.5 130 143/82 28 94%
RA
DISEASE
. Shedeveloped a worsening O2 requirement to 5L nc and receivedvanco levofloxacin and ceftriaxone. She was then admitted tothe [**Hospital Unit Name 153**] for further management..Currently the patient continues to complain of
dyspnea
DISEASE
and
cough
DISEASE
.
Denies
DISEASE
any CP palpitations or assymetric lowerextremity
edema
DISEASE
.Past Medical History:BREAST CANCER:- [**2170**] - diagnosed with 4 cm right breast infiltrating ductal
carcinoma
DISEASE
grade 3
LVI
DISEASE
ER/PR/Her-2/neu Admission Date: [**2160-11-15**] Discharge Date: [**2160-11-28**]Date of Birth: [**2079-11-28**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2186**]Chief Complaint:
dyspnea
DISEASE
Major Surgical or Invasive Procedure:1. VATS2. Bilateral chest tubesHistory of Present Illness:The patient is an 80 year old Russsian speaking man with
coronary artery disease
DISEASE
decreased LV function without priorsymptoms of
congestive heart failure hypertension
DISEASE
and atrial
fibrillation
DISEASE
(on coumadin) status post pacemaker and a recentdiagnosis of
malignant ascites
DISEASE
(non small cell CA vs.
adenocarcinoma
DISEASE
) primary unknown who presents with hypoxia at88% on
RA
DISEASE
. Per the patient and his daughter the patient beganhaving increased
dyspnea
DISEASE
over the past two to three days whichwas associated with a mild increase in pedal
edema
DISEASE
and a largeincrease in his
abdominal ascites
DISEASE
.Of note the patient denies CP new
cough
DISEASE
recent URI urinarySX
HA dizziness myalgias arthralgias
DISEASE
F/C. He had mild
abdominal pain
DISEASE
decreased appetite mild
nausea
DISEASE
without
emesis
DISEASE
.He has hard BM every other day. He denies any recent traveland has been relatively immobile.Past Medical History:
HTN
DISEASE
GERD
DISEASE
BPHs/p thymectomoy with partial sternotomy in '[**59**] (for mediastinalmass seen incidentally on CT)CAD (last cath here in '[**47**] showed minor branch coronary arterydisease in the OM2 sees Dr. [**Last Name (STitle) **]
CHF
DISEASE
(last TTE here in '[**51**] EF 30-35% mild-severe MR mild-modTR)
Afib
DISEASE
(on coumadin)h/o pulmonary noduless/p pacemaker placement [**2149**]s/p R
cataract
DISEASE
surgerySocial History:Lives in Admission Date: [**2171-4-4**] Discharge Date: [**2171-4-9**]Date of Birth: [**2086-10-29**] Sex: FService: MEDICINE
Allergies
DISEASE
:Calcium Channel BlockersAttending:[**First Name3 (LF) 2108**]Chief Complaint:
hypoxia
DISEASE
lip and tongue
swelling
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:84yo w/PMHx significant for
HTN
DISEASE
CKD
CVA
DISEASE
(
hemiplegia
DISEASE
in [**2155**])
diastolic heart failure
DISEASE
HLD
PVD
DISEASE
refered from [**Hospital 100**] rehabafter bolus fluids for [**Last Name (un) **] given poor PO intake and elevated Cron labs (felt to be
pre-renal
DISEASE
) and lasix held yesterday. Howeverafter fluids bolus of 1L pt became hypoxic to 85% w/crackles. Kelevated to 5.5 at [**Hospital **] rehab got kayexalete. She was thengiven 60mg lasix w/out much improvement despite diuresis atwhich point transferred to [**Hospital1 18**]. Pt has had gradual decline inMS (somnolent but no
confusion
DISEASE
). Also developed large tongueand protruding lower lip concerning for
angioedema
DISEASE
in setting ofchronic ACEI use. However per report
swelling
DISEASE
developed slowlysince her recent ED admission on [**2171-4-1**] during which she wasstarted on augmentin. Other than this she has had no medicationsbut has been on enalapril for extended period (durationunknown).Of note pt was hospitalized Admission Date: [**2171-8-10**] Discharge Date: [**2171-8-14**]Date of Birth: [**2086-10-29**] Sex: FService: MEDICINE
Allergies
DISEASE
:Calcium Channel Blockers / Ace Inhibitors / AmoxicillinAttending:[**First Name3 (LF) 2605**]Chief Complaint:Bright red blood per rectumMajor Surgical or Invasive Procedure:noneHistory of Present Illness:84yo w/PMHx significant for
HTN CKD CVA
DISEASE
(L sided weakness in[**2155**]) chronic
diastolic heart failure hyperlipidemia
DISEASE
PVD p/wBRBPR. The pt is a resident of [**Hospital 100**] Rehab where she was foundto have dark stools and
abdominal pain
DISEASE
. HCT was checked and wasfound to be 30 down from 32 on [**8-6**]. She was transferred to[**Hospital1 18**] and en route EMS noticed significant bright red bloodsystolic blood pressure trending down from 130 to 110 at [**Hospital 100**]Rehab and down to 100 in the ambulance..In the ED the pt was 95.0 96 105/57 18 100% 4L Nasal Cannula.She had significant BRBPR and was found to have HCT 25.7.Because of a Cr 2.0 CTA was not done. The family was at bedsideand reinforced that the the pt was DNR/DNI no CVL but ok togive peripheral blood. GI was made aware. She was given 2L NSstarted on protonix gtt type and crossed and one bag of pRBCswas hung. On repeat VS HR 85 BP 104/49 RR 25 O2 100% 2L NC..On the floor the patient was comfortable A&Ox3 afebrile withBP 151/63 HR 70 satting 100% on 2Lnc. She continued to complainof diffuse
abominal pain
DISEASE
but no symptoms of lightheadednessdizziness CP or SOB. Her family decided that they would be okwith CVL and intubation for procedure if necessary..Of note the pt has
macroglossia
DISEASE
and
asymmetric lip swelling
DISEASE
that was thought to be
angioedema
DISEASE
during an admission in [**Month (only) 116**].Per the family her current appearance has been stable forseveral months. The pt denies sob increased tongue
swelling
DISEASE
throat swelling
DISEASE
or
respiratory distress
DISEASE
..Review of systems:(Admission Date: [**2120-9-26**] Discharge Date: [**2120-10-9**]Date of Birth: [**2080-8-6**] Sex: MService: Plastic SurgeryREASON FOR ADMISSION: The patient was transferred from [**Hospital3 418**] Hospital via med-flight status post [**2080**]5 feetout of a tree with extensive facial
fractures
DISEASE
.HISTORY OF PRESENT ILLNESS: The patient is a 44-year-oldgentleman who fell 25 feet four hours prior to arrival at[**Hospital1 69**] after an intermediatestop at an outside Emergency Department ([**Hospital3 417**]Hospital) who intubated the patient for airway protection andlife-flighted him to the
trauma
DISEASE
unit here.PAST MEDICAL HISTORY: The patient's past medical history onpresentation was negative (per report). The patient wasintubated.REVIEW OF SYSTEMS: Review of systems was negative.PHYSICAL EXAMINATION ON PRESENTATION: The patient's bloodpressure on arrival was 137/81. His heart rate was in the80s. He was intubated at 99%. His pupils were equal roundand reactive to light and accommodation. There was blood inhis nares. A mobile hard palate was appreciated and he hadthree
lacerations
DISEASE
on the left cheek. His tympanic membraneswere clear. He had a
chin laceration
DISEASE
as well. He was placedin a cervical collar. No obvious
deformity
DISEASE
was appreciated.His lungs were clear to auscultation bilaterally. Hisabdomen was soft nontender and nondistended. A left upperquadrant abrasion was noted. His peritoneum wasguaiac-negative. His prostate was okay. His extremitiesrevealed a
left shoulder contusion
DISEASE
. Pulses were found in alldistal extremities and in all
upper extremities
DISEASE
. He movedall extremities spontaneously. His back and spine revealedthere was no deformity. He was on a back board onpresentation. His [**Location (un) 2611**]
Coma
DISEASE
Scale on presentation was 7.PAST MEDICAL HISTORY: Further information was obtained fromthe family regarding the patient's past medical history of
hypertension
DISEASE
high cholesterol and
gastroesophageal reflux
DISEASE
disease.MEDICATIONS ON DISCHARGE: His medications were [**Doctor First Name **] andLipitor.ALLERGIES: He had an
allergy
DISEASE
to PROTONIX (from which he gota
rash
DISEASE
).SOCIAL HISTORY: Occasional alcohol. A nonsmoker.PERTINENT LABORATORY VALUES ON PRESENTATION: Hislaboratories on presentation revealed his white blood cellcount was 13.8 his hematocrit was 37.7 and his plateletswere 245. His sodium was 144 potassium was 4.2 chloridewas 108 bicarbonate was 24 blood urea nitrogen was 19creatinine was 0.8 and blood glucose was 155. His amylasewas 59. His prothrombin time was 12.7 partialthromboplastin time was 18.4 and his INR was 1.1.Toxicology screen was negative. Gas was 7.34/45/92/28 with abase deficit of -1. The patient was on synchronizedintermittent mandatory ventilation at 700 50% FIO2 and apositive end-expiratory pressure of 5.PERTINENT RADIOLOGY/IMAGING: A chest x-ray was negative.A pelvic x-ray was negative.A computed tomography of the abdomen and pelvis was negative.CONCISE SUMMARY OF HOSPITAL COURSE: The diagnosis at thetime of presentation was
loss of consciousness
DISEASE
and maxillary
fracture
DISEASE
. The patient was admitted to the
Trauma
DISEASE
SurgicalIntensive Care Unit. Cervical spine films cervical collarACT
tetanus
DISEASE
antibiotics and a Plastic Surgery wasinitiated.Plastic Surgery saw the patient the same evening. Theyarrived to find the patient sedated. The patient wasintubated and sedated. Facial laceration of 5 cm and a chinlaceration were sutured. Open
mandible fracture
DISEASE
midline andopen
palate
DISEASE
and
ecchymosis
DISEASE
of the left eye. Tympanicmembranes were clear bilaterally. No septal
hematoma
DISEASE
wasappreciated. Facial bones were palpated. Stepoff was notedat palate.At this juncture two coronal computed tomography scans wereinitiated for evaluation of facial
fractures
DISEASE
. Oral andMaxillofacial Surgery was initiated. An Ophthalmologyconsultation was initiated. The patient was placed onclindamycin and sutures of laceration for repair.On postoperative day one the patient continued to behemodynamically stable. His respiratory system was clear.His abdomen was soft with
positive bowel sounds
DISEASE
. Sociallyhis wife was updated on his status as an Intensive Care Unitresident and the patient was stable.On hospital day two officially the cervical spine wascleared. The patient was evaluated by the Plasticsattending. Le Fort I and Le Forte II palatal fracture. Theplan was for open reduction/internal fixation of facial
fractures
DISEASE
after cervical spine clearance.On hospital day two Ophthalmology came by. On computedtomography there was already apparent with a lateral
orbital fracture
DISEASE
nondisplaced with no evidence of globe
rupture
DISEASE
. The left lateral orbital wall fracture. Consensualpupil reflexes were intact.On hospital day three the patient continued to be stable.He did spike a temperature with a temperature maximum of 101degrees Fahrenheit. Urine cultures were initiated whichturned out to be negative.On hospital day four tube feeds were started. The patient'stemperature maximum was 101.2 degrees Fahrenheit. Thepatient remained stable and intubated.On hospital day five the patient continued to be stable. Noevents of significance. The patient was made nothing bymouth at midnight with a plan to take the patient to theoperating room on hospital day six.The patient was taken to the operating room for openreduction/internal fixation of
multiple facial fractures
DISEASE
.Please see the Operative Report. The patient tolerated theprocedure well. The patient was stable postoperatively witha patent airway and was kept intubated overnight. His headwas elevated. The patient was placed in a maxillarymandibular fixation.On postoperative day one hospital day seven the patientcontinued to do well. The patient did spike a temperature to103.1 degrees Fahrenheit. In addition to clindamycin thepatient was placed on levofloxacin.On hospital day seven postoperative two the patientcontinued to be intubated secondary to facial edema. ADobbhoff tube was placed and tube feeds were once againstarted. Maxillary computed tomography scan was taken againand with input of Oral and Maxillofacial Surgery thecondylar displacement was once again evaluated and judged tobe stable. Further evaluation will be determined throughOral and Maxillofacial Surgery. The patient's hematocrit onhospital day seven required a transfusion of 2 units ofpacked red blood cells with further hematocrit levels beingascertained. Input was once again given by Oral andMaxillofacial Surgery. All
fractures
DISEASE
were reduced. Thepatient was stable from a Plastic Surgery perspectiveAdmission Date: [**2118-2-12**] Discharge Date: [**2118-2-23**]Date of Birth: [**2043-12-16**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2387**]Chief Complaint:
dyspnea
DISEASE
Major Surgical or Invasive Procedure:cardiac catheterization [**2118-2-17**]removal of retained catheter with left lower extremityarteriogram and placement of left external iliac covered andbare metal stents [**2118-2-17**]History of Present Illness:Ms. [**Known lastname 2627**] is a 74F with
DM
DISEASE
and
CHF
DISEASE
(EF 50-55%) on chronicsteroid treatment who presents with increased shortness ofbreath and
tachypnea
DISEASE
at her living facility..Of note she was recently hospitalized from [**Date range (1) 2628**] for anonhealing RLE
ulcer
DISEASE
. She underwent partial
thickeness
DISEASE
skingrafting and was treated with a variety of antibiotics:initially vancomycin ciprofloxacin flagyl then cefazolin andzosyn ultimately discharged on meropenem for
Enterobacter UTI
DISEASE
.Prior to discharge she developed chest discomfort and was ruledout for
myocardial infarction
DISEASE
. She also developed increased
pulmonary edema
DISEASE
and the cardiology consult recommendedincreasing his lasix to 40mg daily -- though she was dischargedon only 20mg daily..The day prior to admission she developed increasing
dyspnea
DISEASE
and
tachypnea
DISEASE
. Per daughter but not patient she was coughing aswell but patient did not have
fevers chills
DISEASE
or sweats..ROS: No PND or orthopnea leg
pain
DISEASE
asymmetry h/o
thrombosis
DISEASE
chest discomfort nausea vomiting abdominal pain
DISEASE
diarrhea/constipation. Does complain of
sore
DISEASE
buttocks..She was initially sent to an OSH where she was treated with 40mgIV lasix 750mg levofloxacin and sent to [**Hospital1 18**] for furthermanagement..In the ED here here vitals were T 97.6 P 102 BP 133/81 RR notrecorded O2 83% on room air improving to mid 90's on 2-3L. Herchest film showed
cardiomegaly
DISEASE
and [**Hospital1 1106**] congestionconsistent with
heart failure
DISEASE
though there was a question of Lretrocardiac
opacity
DISEASE
.On the floor she complained of
palpitations
DISEASE
and
dyspnea
DISEASE
improved at time of interview.Past Medical History:* RLE
ulcer
DISEASE
x1 year*
HTN
DISEASE
* DM poorly controlled per report*
Hyperlipidemia
DISEASE
*
Obesity
DISEASE
*
Breast cancer
DISEASE
3-4 years PTA per daughter s/p surgery andradiation no chemo*
CHF
DISEASE
systolic EF 50-55%* Admission Date: [**2123-2-25**] Discharge Date: [**2123-4-23**]Date of Birth: [**2040-1-17**] Sex: MService: EMERGENCY
Allergies
DISEASE
:Aspirin / Codeine / Penicillins / Bactrim / Heparin Agents /TetanusAttending:[**First Name3 (LF) 2565**]Chief Complaint:R hip
pain
DISEASE
Major Surgical or Invasive Procedure:Closed reduction of right hipTracheostomyPlacement of gastric tubeIntubationsHistory of Present Illness:83yo Arabic speaking male with multiple medical problemsincluding
dementia HTN COPD GERD
DISEASE
BPH
osteoporosis CKD
DISEASE
prior
GI bleed
DISEASE
secondary to
ulcer
DISEASE
[**1-/2120**] and hx of hipreplacement presenting with right hip
pain
DISEASE
. Hip pain startedafter bumpy car ride on [**2-19**]. At baseline patient is inwheelchair and can ambulate with assistance. Since car ride sonhas noticed that patient can no longer stand up straight or goup stairs. Has tried tylenol with little relief for
hip pain
DISEASE
. Nofever/chest pain/SOB/abd pain/new focal neurologic changes.
Currenly
DISEASE
on lovenox for PE diagnosed in [**Month (only) 205**] also gettingdressing changes for bilateral shin
ulcers
DISEASE
and a
coccyx ulcer
DISEASE
.The patient's mental status is at baseline per son.In the ED initial vs were: T 99 P 93 BP 131/79 R 20 O2 sat 98%on
RA
DISEASE
. The patient was given acetaminophen for
pain
DISEASE
Patient wasevaluated by ortho trauma who are planning to attempted aclosed reduction tomorrow AM for a displaced acetabular ringseen by Xray.Past Medical History:1.
Hypertension
DISEASE
.2.
Renal artery stenosis
DISEASE
.3.
Chronic obstructive pulmonary disease
DISEASE
.4.
Gastroesophageal reflux disease
DISEASE
.5.
Chronic constipation
DISEASE
.6. Benign
prostatic hypertrophy
DISEASE
.7.
Peptic ulcer disease
DISEASE
.8. Insulin resistance.9.
Memory loss
DISEASE
.10.
Osteoporosis
DISEASE
.11. Gait instability with history of falls.12. History of
GI bleed
DISEASE
secondary to
ulcer
DISEASE
01/[**2120**].13.
Weight loss
DISEASE
.14. Left lower extremity
DVT
DISEASE
.15. Status post hip
fracture
DISEASE
[**2120**].16.
Chronic kidney disease
DISEASE
.17. History of aspiration.18.
Nondisplaced pelvic fracture
DISEASE
05/[**2120**].19.
Peripheral vascular disease
DISEASE
with
lower extremity ulcers
DISEASE
.20.
Renal lesion
DISEASE
.21.
Pancreatic cystic lesion
DISEASE
.22.
Pneumonia
DISEASE
01/[**2122**].23. PE in [**7-/2122**] on lovenox.PAST SURGICAL HISTORY:1. Right
cataract
DISEASE
removal.2. Right total hip arthroplasty 01/[**2120**].3. Inguinal
hernia
DISEASE
repair.Social History:Smoked for 30 years (heavily). Rare ETOH now. The patient liveswith his son who is the only caretakerAdmission Date: [**2170-3-22**] Discharge Date: [**2170-4-8**]Date of Birth: [**2102-3-5**] Sex: MService: MEDICINE
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 2641**]Chief Complaint:SOB
hypercapnea
DISEASE
Major Surgical or Invasive Procedure:endotracheal intubationHistory of Present Illness:68M with history of
COPD
DISEASE
(on 2-3L O2 at home) with history ofmultiple intubations CAD with
ischemic cardiomyopathy
DISEASE
(EF20-25%) who was transferred to [**Hospital1 18**] from an outside hospital on[**2170-3-22**] with SOB. Pt initially noted
fever
DISEASE
to 102 4 days priorto admission. However patient was without respiratorycomplaints or
cough
DISEASE
. Pt was started on course of Azithromycinas an outpatient for suspected
bronchitis
DISEASE
and reports someimprovement in pulm Sx. The evening prior to admisssion thepatient became progressively dyspnic with a minimally-productive
cough
DISEASE
.Pt presented to an outside hospital where he was found to haveHR 150 that was believed to be possible Aflutter but perreport was found to be
sinus tachcardia
DISEASE
. CXR per report wasconsistent with mild
CHF
DISEASE
and possible RML PNA. ABG on 100% NRBwas 7.25/61/77. Further treamtent at outside hospital includedASA 325 NTG SL times 2 Alb/Atr nebs Lasix 60 mg IVSloumedrol 125mg IV Ceftriaxone and Moxifloxacin. Pt wassubsequently transferred to [**Hospital1 18**] for further management.On arrival to MICU [**2170-3-22**] pt felt Admission Date: [**2153-3-6**] Discharge Date: [**2153-3-12**]Service: CCUCHIEF COMPLAINT:
Hypotension
DISEASE
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old femalewith a history of
coronary artery disease
DISEASE
status post
myocardial infarction
DISEASE
in [**2150**]
hypertension
DISEASE
and
hypercholesterolemia
DISEASE
recently admitted for evaluation of aright ankle
ulcer/cellulitis
DISEASE
. She was discharged to homewith Keflex on [**2-24**] with a 7 to 10 day course of antibioticscheduled. She was brought in today by her daughter afterbeing found down in her apartment. The daughter was out oftown for the last five days returned today and found thepatient down on the afternoon of admission. She had seen thepatient the night before and the two had had dinner and therewere no problems at that time. There was no loss ofconsciousness. By the patient's report there was no chest
pain shortness of breath nausea vomiting
DISEASE
no
head trauma
DISEASE
.By the daughter's report the patient had not been taking anyof her medications for the last five days.PAST MEDICAL HISTORY:1. Hypertension2. Hypercholesterolemia3. Coronary
artery disease
DISEASE
status post myocardial
infarction
DISEASE
in [**2150-12-12**]. ETT with inferolateralreproduced perfusion defect moderate
mitral regurgitation
DISEASE
mild to moderate AS. Ejection fraction greater than 55% on[**2150-12-12**].4.
Hypothyroidism
DISEASE
on chronic replacement5. Diverticulosis last colonoscopy in [**Month (only) 404**] of '[**49**]6. External hemorrhoids7. Status post fall with a
pubic ramus fracture
DISEASE
8. History of
pyuria
DISEASE
with AFB x39. DementiaADMISSION MEDICATIONS:1. Levoxyl 75 mcg po qd2. Celexa 30 mg po qd3. Cozaar 25 mg po qd4. Anusol HC5. Imdur 30 mg po qd6. Iron sulfate7. Lasix 20 mg po qd8. Lipitor 10 mg po qd9. MVI 1 tablet po qd10. Lopressor 25 mg po bid11. Aspirin 325 mg po qd12. Keflex 250 mg po qidALLERGIES: No known drug
allergies
DISEASE
.SOCIAL HISTORY: The patient lives alone. Her daughter isher healthcare proxy and the telephone number ([**Telephone/Fax (1) 2651**].There is no tobacco or alcohol history.PRIMARY CARE PHYSICIAN: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2184**] [**Last Name (NamePattern1) **]ADMISSION PHYSICAL
EXAM
DISEASE
:VITAL SIGNS: Temperature 97.3Admission Date: [**2139-8-20**] Discharge Date: [**2139-8-23**]Date of Birth: [**2076-7-31**] Sex: MService: CardiothorHISTORY OF PRESENT ILLNESS: The patient is a 63-year-oldmale who is otherwise healthy who was evaluated for a
systolic murmur
DISEASE
. Work up revealed a
mitral regurgitation
DISEASE
three years ago. He was followed since then but hadworsening symptoms and now came for operative repair. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**] M.D. [**MD Number(1) 414**]Dictated By:[**Last Name (NamePattern1) 3214**]MEDQUIST36D: [**2139-8-23**] 10:50T: [**2139-8-26**] 15:58JOB#: [**Job Number 3215**]Admission Date: [**2139-8-20**] Discharge Date: [**2139-8-23**]Date of Birth: [**2076-7-31**] Sex: MService: CardiothorHISTORY OF PRESENT ILLNESS: The patient is a 63-year-oldmale who is otherwise healthy who was evaluated for a
systolic murmur
DISEASE
. Work up revealed a
mitral regurgitation
DISEASE
three years ago. He was followed since then but hadworsening symptoms and now came for operative repair. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**] M.D. [**MD Number(1) 414**]Dictated By:[**Last Name (NamePattern1) 3214**]MEDQUIST36D: [**2139-8-23**] 10:50T: [**2139-8-26**] 15:58JOB#: [**Job Number 3216**]Admission Date: [**2103-7-26**] Discharge Date: [**2103-8-9**]Date of Birth: [**2072-5-4**] Sex: FService: [**Doctor First Name 147**]
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 1556**]Chief Complaint:
abdominal pain
DISEASE
Major Surgical or Invasive Procedure:Status post exploratory laparatomystatus post right colectomystatus post appendectomystatus post abdominal closureHistory of Present Illness:31 yo Female who was status post normal spontaneous vaginaldelivery approximately 10 weeks ago who presented on [**2103-7-25**]with a chief
complaint
DISEASE
of
abdominal pain
DISEASE
. She was well untilabout 12 hours prior to admission when she described the acuteonset of sharp right lower quadrant
pain
DISEASE
and diffuse/poorlycharacterized dull general
abdominal pain
DISEASE
. The
pain
DISEASE
wasdescribed as sharp constant. The
pain
DISEASE
radiated to the back.It got worse with motion better with motrin. The
pain
DISEASE
wasassociated with
nausea
DISEASE
and
bilious vomiting
DISEASE
times 1 subsequentto the onset of
pain
DISEASE
. The patient also described subjective
fevers
DISEASE
and
chills
DISEASE
. The paitent did not have any
constipation
DISEASE
diarrhea
DISEASE
change in the color of her
stools dysuria hematuria
DISEASE
vaginal discharge itching
DISEASE
or
bleeding
DISEASE
. No history of recetntruama travel. she has not been sexually active since herdeliveryPast Medical History:recurrent
respiratory infections
DISEASE
allergies
DISEASE
Gastroesophageal reflux disease
DISEASE
removal of
cystic mass
DISEASE
of breastremoval of
labial cyst
DISEASE
degenerating
fibroid
DISEASE
during pregnancySocial History:works in a research labno tobacco or alcoholtravelled to [**Country 2045**] in [**2081**] bermuda in [**2088**]Family History:No history of
bowel problems
DISEASE
. Father had a history of
hypertension
DISEASE
Physical Exam:temperature 100.8 pulse 81 blood pressure 109/71 respirations16 oxygen saturation 100% on room airGeneral: patient was in moderate distress appeared acutely illHead and neck: head atraumatic/normocephalic. sclera anicteric.No
lymphadenopathy
DISEASE
no jvdCard: regular rate and rhythmLungs: clear to auscultationAbdomen: soft mildly distended. Diffuse tenderness RLQAdmission Date: [**2133-10-22**] Discharge Date: [**2133-10-26**]Date of Birth: [**2091-3-27**] Sex: FService: NEUROSURGERY
Allergies
DISEASE
:AmoxicillinAttending:[**First Name3 (LF) 3227**]Chief Complaint:Residual Rt Frontal MassMajor Surgical or Invasive Procedure:[**2133-10-22**]: Right Craniotomy for mass resectionHistory of Present Illness:Patient is a 42F electively admitted for right craniotomy formass resection. She had prior surgery with Dr. [**First Name (STitle) 3228**] on [**10-2**]but intraop lesion was found to infiltrate the bone table andbrain parenchyma. Surgery was further aborted pendingneurosurgical consultation and planning for complete resection.Past Medical History:s/p aborted r frontal mass [**Last Name (LF) 3229**] [**First Name3 (LF) 3228**] [**10-2**]
HTN
DISEASE
anxiety insomnia
DISEASE
and
hypercholesterolemia
DISEASE
Social History:non-contributoryFamily History:non-contributoryPhysical Exam:Upon discharge:Alert and oriented to person place and time. MAE with 5/5strength. Neuro exam is nonfocal intact. Head incision is C/D/Iwith dissolveable sutures.Ambulating steadily with normal gait. Tolerating POs.Pertinent Results:Labs on Admisson:[**2133-10-22**] 05:27PM BLOOD WBC-11.7* RBC-3.94* Hgb-10.9* Hct-33.3*MCV-85 MCH-27.7 MCHC-32.8 RDW-14.0 Plt Ct-389[**2133-10-22**] 05:27PM BLOOD Glucose-175* UreaN-10 Creat-0.7
Na-144
DISEASE
K-4.5 Cl-111* HCO3-25 AnGap-13[**2133-10-22**] 05:27PM BLOOD Calcium-9.3 Phos-3.9 Mg-1.7Imaging:Post-op MRI [**10-23**]: IMPRESSION: Expected post-surgical changesare seen following resection of a large bony
tumor
DISEASE
within theskull in the right frontoparietal region. Pneumocephalus andsmall amount of blood products are seen in the region. No acute
infarcts
DISEASE
or
hydrocephalus
DISEASE
.Brief Hospital Course:Patient was electively admitted for completion of right sided
tumor
DISEASE
resection. Post-operatively she was observed in the ICUfor 24 hours. On POD#2 she was transfer to the NSURG floorneuro exam remained intact. Post-operative MRI revealed completeresection of the lesion. She tolerated POs and was cleared byPT for discharge home. She was discharged on [**2133-10-26**].Medications on Admission:Acyclovir [**Doctor Last Name **]Fluticasone nasal sprayHCTZ 25mg dailyLabetolol 100mg [**Hospital1 **]Discharge Medications:1. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a dayfor 7 days.Disp:*14 Capsule(s)* Refills:*0*2. Acetaminophen 160 mg/5 mL Solution Sig: [**12-26**] PO Q6H (every 6hours) as needed for pain/TAdmission Date: [**2144-8-24**] Discharge Date: [**2144-8-27**]Date of Birth: [**2097-5-29**] Sex: FService: MEDICINE
Allergies
DISEASE
:Heparin Agents / Codeine / Zosyn / CeftriaxoneAttending:[**First Name3 (LF) 689**]Chief Complaint:
Hypoxia
DISEASE
and
Eosinophilia
DISEASE
Major Surgical or Invasive Procedure:bronchoscopyHistory of Present Illness:The patient is a 47y/o F with a PMH of EtOH abuse recenthospitalization for PNA presenting with
hypoxia
DISEASE
. The patient washospitalized [**Date range (1) 3246**] after presenting with
fever chills
DISEASE
andSOB. She had been staying at an etoh rehab facility on [**Hospital3 **]starting [**7-12**]. She presented to [**Hospital3 **] hospital on [**7-30**] withCP and
fever
DISEASE
to 102. CXR at that time demonstrated a PNA and shewas given a course of ceftriaxone-Admission Date: [**2170-8-20**] Discharge Date: [**2170-8-25**]Date of Birth: [**2096-8-16**] Sex: MService:CHIEF COMPLAINT: Bright red blood per rectum.HISTORY OF PRESENT ILLNESS: This is a 74-year-old gentlemanwith a history of
bleeding
DISEASE
internal hemorrhoids status postcauterization seven days prior to admission who was startedon Plavix three days prior to admission. He was admitted tothe medical Intensive Care Unit for bright red blood perrectum. The patient said the
bleeding
DISEASE
started suddenly at 2o'clock PM on the day of admission with passing large clotsand bright red blood per rectum. This was not associatedwith
abdominal pain nausea fevers chills diarrhea
DISEASE
. Thepatient reports he has bright red blood per rectum on a dailybasis this is basically self-limited.REVIEW OF SYSTEMS: The patient complains of severe rectal
pain
DISEASE
. No complaints of
chest pain dyspnea
DISEASE
short of breathor
dysuria
DISEASE
.In the emergency department the patient continued to haveprofuse bright red blood per rectum and was transfused twounits of packed red blood cells. His blood pressure haddecreased systolic blood pressure in the 80's which wascorrected by fluid boluses. Colonoscopy revealed an actively
bleeding
DISEASE
internal hemorrhoid which was ligated.PAST MEDICAL HISTORY:1. Internal hemorrhoids.2. Diverticula and
polyp
DISEASE
seen on [**6-21**] colonoscopy.3. Chronic
renal insufficiency
DISEASE
with a baseline creatinine of2 to 3 thought to be secondary to
hypertensive
DISEASE
glomerulusscleras.4.
Atrial fibrillation
DISEASE
.5. Cerebrovascular accident on [**7-22**].6. Obstructive sleep apnea intolerance of CPAP.7. Hypercholesterolemia.8. Anemia.ALLERGIES: No known drug allergies.MEDICATIONS:1. Plavix 75 mg p.o. q day.2. Diovan 80 mg p.o. q day.3. Allopurinol 100 mg p.o. q day.4. Zantac.5. Lipitor.6. Epoetin 10000 units q week.7. Iron.SOCIAL HISTORY: The patient lives with his wife. Quitsmoking several years ago no alcohol no intravenous druguse.PHYSICAL EXAMINATION: On admission temperature was 97.4blood pressure 192/47 heart rate 16 sating 100% on twoliters nasal cannula. General: Alert and oriented timesthree. Some discomfort in the rectal area. Head eyesears nose and throat: Pupils are equal round and reactiveto light and accommodation.
Extraocular movements
DISEASE
intact.Dry mucous membranes. Neck: Supple no
lymphadenopathy
DISEASE
or
jugular venous distention
DISEASE
. Pulmonary: Clear to auscultationbilaterally. Cardiac: Bradycardiac. Regular. S1 and S2.No murmurs rubs or gallops. Abdomen: Obese nontender.Normal
active bowel sounds
DISEASE
no
organomegaly
DISEASE
. Extremities:No
cyanosis clubbing
DISEASE
or
edema
DISEASE
. 2Admission Date: [**2172-1-5**] Discharge Date: [**2172-2-13**]Date of Birth: [**2096-8-16**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 99**]Chief Complaint:Weakness /
confusion
DISEASE
Major Surgical or Invasive Procedure:Placement of a SVC tunnelled hemodialysis catheterPlacement of a subclavian central linePlacement of a percutaneous cholecystostomyIntubationPlacement of a femoral central lineHistory of Present Illness:This 75 year old man with a past medical history significant forCVA
atrial fibrillation
DISEASE
and
chronic renal insufficiency
DISEASE
presented with worsening
confusion
DISEASE
&
agitation
DISEASE
x 1 day. He alsohad
headache nausea
DISEASE
unsteady gait dyspnea on exertion and
dizziness
DISEASE
. His wife called the patient's primary care doctorwho referred them to the emergency department. According to thepatient's wife these symptoms had been getting progressivelyworse over the past 3 weeks. The patient denied
pruritis
DISEASE
chest
pain shortness of breath or abdominal pain
DISEASE
..The patient was seen by his PCP [**Last Name (NamePattern4) **] [**2172-1-2**] (3 days prior toadmission) and at that time had malise fatigue poor appetitedifficulty walking and
nausea
DISEASE
. He had an unchanged MRI of hishead at that time and his BUN/cr were elevated but close to hisbaseline 78 & 5.7 respectively). During that office visit hedenied
shortness of breath chest pain abdominal pain nausea
DISEASE
or
diarrhea
DISEASE
. He did mention that he had started takingamitriptyline one week prior.Past Medical History:- cerebrovascular accident with
residual aphasia
DISEASE
-
atrial fibrillation
DISEASE
-
hypertension
DISEASE
-
chronic renal insufficiency
DISEASE
(creat baseline 5.0-5.3)-
Anemia
DISEASE
-
Gout
DISEASE
Social History:lives with wife lives on [**Location (un) 470**] with elevatorFamily History:Non-contributoryPhysical Exam:VS: afebrile vital signs stableHEENT: NCAT PERRL anicteric EOMI MMMNeck: supple no LAD no JVD no
carotid bruits
DISEASE
Resp: Bibasilar cracklesCards: RRR nl S1 S2 no m/g/rAbd: nl BS soft NT ND no HSMExt: no
edema
DISEASE
Admission Date: [**2147-12-6**] Discharge Date: [**2147-12-9**]Date of Birth: [**2110-3-12**] Sex: FService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 3256**]Chief Complaint:lethargy
DKA
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:37F with PMH
DM1
DISEASE
transferred from OSH for
lethargy
DISEASE
and
DKA
DISEASE
. Ptrelates that last week she developed severe
headaches
DISEASE
for whichher PCP got an MRI and diagnosed her with
cluster headache
DISEASE
. Shehad a tooth filled 3 week prior and last week damaged the toothopening a bottle with it. Her dentist again filled the toothlast Friday and over the past week she has been treated for aright sided
tooth infection
DISEASE
initially with amoxicillin but shedeveloped worsened
pain
DISEASE
and was switched to flagyl. On Saturdayshe noted significantly increased right sided facial swellingand pressure. Two days prior to admission she experienceddrainage of purulent material from the gums surrounding the
infected tooth
DISEASE
.
Denies fever chills diarrhea dysuria
DISEASE
pelvic
pain cough
DISEASE
sputum production. She concommitently developed
fatigue lethargy vomiting nausea
DISEASE
with decreased PO intake.She has been taking her usual insulin regimen of lantus 16 Qhsplus mealtime lispro 3-5unit SS with finger sticks not above208. At the OSH labs included glucose 389 AG 18 for which shegot 4L IVF 6U IV insulin started on insulin gtt..In the ED inital vitals were T 98.9 HR 115 BP 118/74 RR 20 Sat100%RA FSG 172. Insulin drip was stopped but was restarted withD5NS Admission Date: [**2201-4-2**] Discharge Date: [**2201-4-20**]Date of Birth: [**2138-12-24**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 633**]Chief Complaint:Left hip
pain
DISEASE
Major Surgical or Invasive Procedure:s/p L hip resectionHistory of Present Illness:yo male with history of
HTN
DISEASE
GERD EtOH
cirrhosis Crohn's
DISEASE
s/pileostomy
COPD depression pancytopenia avascular necrosis
DISEASE
[**1-7**] chronic prednisone use s/p L hip replacement presentingoriginally for planned L hip revision but was found unable tobe revised because of advanced
osteolysis
DISEASE
and so is now s/ptotal resection arthroplasty. Patient noted to be confusedovernight. Per ortho team patient had also been confused oncoming out of the OR on [**2201-4-2**] but his mental status clearedup overnight. Had initially been transferred to ICU post surgerybecause of
hypotension
DISEASE
was on pressors with subsequentnormalization of blood pressures and transferred to floor teamon [**2201-4-5**]. He has been quite lucid until last night when he wasagain noted to be confused trying to get out of bed and seeingpeople in his room..Per prior report patient himself says that he feels fatiguedsince his surgical procedure finding that he falls asleep alot. Has been having
nightmares
DISEASE
and Admission Date: [**2201-6-23**] Discharge Date: [**2201-6-29**]Date of Birth: [**2138-12-24**] Sex: MService: ORTHOPAEDICS
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 64**]Chief Complaint:R
hip pain
DISEASE
Major Surgical or Invasive Procedure:[**2201-6-23**]: s/p left total hip revisionHistory of Present Illness:62 year old man with [**First Name9 (NamePattern2) 3262**] [**Last Name (un) 3263**]
cirrhosis
DISEASE
c/b Grade 1 esophagealvarices and past
GIB
DISEASE
's
Crohn's
DISEASE
s/p ileostomy COPD
HTN
DISEASE
pancytopenia
DISEASE
GERD depression avascular
necrosis
DISEASE
[**1-7**] chronicprednisone use s/p L hip replacement with massive
osteolysis
DISEASE
ofpelvis/acetabulum and proximal femur extended femoral osteotomy(clamshell) with multiple open reduction and internal fixationswho is admitted to the ICU for monitoring after 3rd attempt oftotal hip replacement..The patient was previously discharged on [**2201-4-20**] s/p totalresection arthroplasty on [**2201-4-2**]. Post-operatively the patientwas noted to be confused coming out of the OR and overnight. Hewas initially transferred to ICU post surgery because of
hypotension
DISEASE
and was on pressors with subsequent normalization ofblood pressures. Post-op course was also complicated byhepatic/toxic-metabolic
encephalopathy
DISEASE
cleared with rifaximinand lactulose and by
acute kidney injury
DISEASE
.Past Medical History:Past Medical History:-
HTN
DISEASE
-
dyslipidemia
DISEASE
- ascending
aortic aneurysm
DISEASE
not involving the coronary vessels- bicuspid aortic valve- EtOH
cirrhosis c/b esophageal varices
DISEASE
and
bleeding
DISEASE
: baselineliver enzymes ALT 21 AST 30 ALK 190 TBili 1.2-
pancytopenia
DISEASE
: baseline WBC 1.7 Hgb 12.3 Hct 35.8 Plt 54-
thrombocytopenia
DISEASE
-
Crohn's disease
DISEASE
s/p ileostomy-
prostate cancer
DISEASE
-
kyphosis
DISEASE
-
COPD
DISEASE
- GERD-
squamous cell carcinoma
DISEASE
s/p resection- avascular
necrosis
DISEASE
of left hip secondary to prednisone-
depression
DISEASE
- baseline BUN 15 Cr 1.0.Past Surgical History:-
squamous cell carcinoma
DISEASE
excisions x 3 forehead ([**10/2199**])- L distal radius ORIF ([**2196**])- partial colectomy with transverse colostomy and
mucous fistula
DISEASE
- mucous fistula takedown- left wrist surgery- left hip replacement (20 years ago)- avascular necrosis of left hip secondary toCrohn's/prednisone- Complex complete resection arthroplasty of failed left totalhip replacementAdmission Date: [**2181-5-6**] Discharge Date: [**2181-5-11**]Date of Birth: [**2103-9-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 3266**]Chief Complaint:mental status changeMajor Surgical or Invasive Procedure:endoscopyHistory of Present Illness:77 M with pmhx of
pulmonary fibrosis CHF
DISEASE
presents with oneweek history of altered mental status increasing
lethargy
DISEASE
andconfused speech. He was brought to his PCP (Dr. [**Last Name (STitle) 3267**] forevaluation and was referred for a Head CT on 2 days PTAnegative. On the DOA he was found by his son to be slumped inbed minimally responsive confused with
bowel incontinence
DISEASE
and brought to the ED. No report of LOC
trauma
DISEASE
fevers chillshas had continued good PO intake no
diarrhea
DISEASE
per report orcp/sobIn ED VS 97.8 57 184/40 100% 2L given levaquin NS lactulosehead CT was negative. NGL was negative.He was taken to MICU for closer monitoring. TBili was elevatedand ammonia was 114. RUQ U/S revealed
chronic liver disease
DISEASE
changes and hepatology was consulted.Upon improvement of mental status with lactulose he wastransferred back to the floor. On the floor he has nocompliants of
pain
DISEASE
. He denies any F/C/N/V abd
pain
DISEASE
. He doesnote feeling very thirsty.Past Medical History:Interstitial
Fibrosis
DISEASE
CHF
DISEASE
Social History: Lives with wife (with alzheimers) son lives 3 blocks awayindependant own ADLs was driving up to 1 week ago DC'd Etoh 5yrs ago was told to stop o/w [**2-3**] drinks/day quit smoking 25yrs ago but o/w 1-2ppd smoker.Family History:Brother died 40s CADFather died 40s CAD1 Sister healthyPhysical Exam:VS 98.9 98.9 154-187/71-76 68 18 99%2LGEN: slightly agitatedHEENT: PERRL EOMI
icteric sclera dry MM
DISEASE
OP with
thrush
DISEASE
CV: RRR SEM III/VI radiating R carotidABD: Admission Date: [**2181-5-14**] Discharge Date: [**2181-5-20**]Date of Birth: [**2103-9-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 330**]Chief Complaint:readmit for mental status changesMajor Surgical or Invasive Procedure:None.History of Present Illness:77 year-old M with
chronic liver disease pulmonary fibrosis
DISEASE
and
CHF
DISEASE
who presented with altered mental status. He wasrecently discharged (hospitalized from [**Date range (1) 3270**]) from the[**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service for altered mental status increased
lethargy
DISEASE
and
confusion
DISEASE
which was attributed to hepatic
encephalopathy
DISEASE
and
UTI
DISEASE
. Prior to his admission on [**2181-5-6**] thepatient was taking Spironolactone 50 mg daily and Atenolol 50mg daily. Ammonia level on prior admission was 114 and totalbilirubin 4.0. RUQ U/S revealed changes c/w chronic liverdisease patent portal vein and
cholelithiasis
DISEASE
. EGD revealed e/o
portal gastropathy varices
DISEASE
in the lower and middle thirds ofthe esophagus and
esophagitis
DISEASE
. Also of note he was
thrombocytopenic
DISEASE
which was attributed to
chronic liver disease
DISEASE
.Lipid panel revealed high LDL. He also had Guaiac positivestools. Mental status improved with lactulose. He was started onnadalol and a PPI.
Hepatitis A
DISEASE
& B serologies were sent andunremarkable. A1AT was 72 (83-199) [**Doctor First Name **] titer was 1:40.
Hereditary hemochromatosis
DISEASE
mutational analysis was sent..The patient was discharged to rehab on [**2181-5-11**]. On the day ofcurrent admission ([**2181-5-13**]) the NH reports that the patient hadincreased
lethargy
DISEASE
and poor appetite. He was found to be 95% on2L NC. He complained of indigestion to the staff. Per hisfamily he also had
chest pain
DISEASE
the day PTA. Labs demonstrated a
leukocytosis
DISEASE
and worsening LFTs. He received Vancomycin 1 glevofloxacin 750 mg and Flagyl 500 mg in the ED. He wastransferred to the MICU for further management. Cardiology wasconsulted for possible STEMI but did not recommendcatheterization for what is felt to be a recent posterolateralMI. RUQ U/S was limited by gaseous
abdominal distension
DISEASE
butrevealed normal CBD (5mm) and two hypoechoic nodules within theright liver lobe. Pt denies
N/V/orthopnea/platypnea
DISEASE
.Past Medical History:Interstitial
Fibrosis
DISEASE
CHF
DISEASE
Social History:Lives with wife (with alzheimers) son lives 3 blocks awayindependant own ADLs was driving up to 1 week ago DC'd Etoh 5yrs ago was told to stop o/w [**2-3**] drinks/day quit smoking 25yrs ago but o/w 1-2ppd smokerFamily History:Brother died 40s CADFather died 40s CAD1 Sister healthyPhysical Exam:Vitals: T: 97.3 BP: 114/52 (114-125/39-65) P: 67 (65-73) RR:16 (14-21) SaO2: 98% 3L NC I/O: 4267/645 (UOP Admission Date: [**2161-3-2**] Discharge Date: [**2161-3-8**]Date of Birth: [**2089-11-15**] Sex: FService: NEUROSURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2724**]Chief Complaint:
nausea vomiting
DISEASE
Major Surgical or Invasive Procedure:s/p suboccipital craniotomy for
tumor
DISEASE
resection and biopsyHistory of Present Illness:71F with
NSCLC HTN hypercholesterolemia
DISEASE
admitted withrefractory nausea/vomitting since starting Tarceva. She deniesabdominal/chest
pain
DISEASE
SOB diarrhea/constipation or problemsw/bladder
incontinence
DISEASE
. She does have
unsteadiness of gait
DISEASE
aswell as trouble using her right hand.Past Medical History:1.
NSCLC
DISEASE
: prior w/u at [**Hospital1 112**]/[**Company 2860**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3273**])- lungnodules found on preop CXR [**6-14**] CT showed RLL nodule c/w
primary lung cancer
DISEASE
and multifocal
bronchoalveolar carcinoma
DISEASE
PET/CT showed FDG-avid R lung nodule and mediastinal/pericardialLAD s/p bronch/mediastinoscopy with mediastinal LN dissectionwith path showing NSCLC-adenocaAdmission Date: [**2103-11-12**] Discharge Date: [**2103-11-22**]Date of Birth: [**2072-5-4**] Sex: FService: SURGERY
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 1556**]Chief Complaint:ileostomy in place from [**9-3**]Major Surgical or Invasive Procedure:ileostomy takedown on [**2103-11-12**]History of Present Illness:31F had an appendectomy with right colectomy in [**8-4**] withileostomy placement. She is here now for takedown of theileostomy.Past Medical History:recurrent
respiratory infections
DISEASE
allergies
DISEASE
Gastroesophageal reflux disease
DISEASE
removal of
cystic mass
DISEASE
of breastremoval of
labial cyst
DISEASE
degenerating
fibroid
DISEASE
during pregnancySocial History:works in a research labno tobacco or alcoholtravelled to [**Country 2045**]in [**2081**] bermuda in [**2088**]Family History:No history of
bowel problems
DISEASE
. Father had a history of
hypertension
DISEASE
Physical Exam:temp 99.8 HR 80 BP 110/72 RR 16 oxygen 100%
RA
DISEASE
General: NADHead and neck: head atraumatic/normocephalic sclera anictericNo
lymphadenopathy
DISEASE
no jvdCard: regular rate and rhythm with s1s2Lungs: clear to auscultation b/lAbdomen: soft non-distended ileostomy in placeBack: no costovertebral angle tendernessExtremeties: no
edema
DISEASE
no
cyanosis
DISEASE
no
clubbing
DISEASE
Neuro: A Admission Date: [**2118-10-23**] Discharge Date: [**2118-10-30**]Date of Birth: [**2065-7-31**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**Doctor First Name 3290**]Chief Complaint:
cough respiratory distress
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:53 yo M w/ h/o
Down's syndrome
DISEASE
non-verbal at baseline
hypothyroidism cataracts dysphagia
DISEASE
s/p G-tube h/o aspirationpna's hypoNa on 4Lnc QHS who presents w/
cough
DISEASE
and
hypoxia
DISEASE
fromgroup home..Per report patient with acute on chronic
cough
DISEASE
found to desatto 88% on
RA
DISEASE
this AM. Looked as if he were in respiratorydistress. Per OMR had been empirically treated for pna back in[**6-/2118**] w/ multiple notes documenting
cough
DISEASE
..In the ED initial VS were: 98.2 74 92/50 28 100% nrb. Tmax100.2. On exam Admission Date: [**2119-9-10**] Discharge Date: [**2119-9-15**]Date of Birth: [**2065-7-31**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 613**]Chief Complaint:
respiratory distress
DISEASE
Major Surgical or Invasive Procedure:Right internal jugular line ([**9-10**])History of Present Illness:53 yo M w/ h/o
Down's syndrome
DISEASE
non-verbal at baseline
hypothyroidism cataracts dysphagia
DISEASE
s/p G-tube h/o aspirationpna's hypoNa on 4Lnc QHS who presents w/
cough
DISEASE
and
hypoxia
DISEASE
fromgroup home.Per report patient with acute on chronic
cough
DISEASE
found to desatto 88% on
RA
DISEASE
this AM. Looked as if he were in respiratorydistress. Per OMR had been empirically treated for pna back in[**6-/2118**] w/ multiple notes documenting
cough
DISEASE
.In the ED initial VS were: 98.2 74 92/50 28 100% nrb. Tmax100.2. On exam Admission Date: [**2167-11-5**] Discharge Date: [**2167-11-9**]Date of Birth: [**2087-3-14**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:
urosepsis
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:80 Russian female with h/o CAD AF s/p PPM
HTN CHF
DISEASE
(EF45-50%) CRI (Cr 1.5) lung CA s/p resection in [**2153**] chronic
pain
DISEASE
who presents to the ED with complaints of progressive LE
pain
DISEASE
and
weakness
DISEASE
over the past several days to weeks. She alsoc/o incresing DOE at home now limited to [**1-30**] steps. She hasbeen sleeping in a recliner recently with her husband helpingher with most ADLs..She also complained difficulty urinating recently as well assome
constipation
DISEASE
. The
constipation
DISEASE
is not new and it can be 4days between
bowel movements
DISEASE
. The
urinary difficulties
DISEASE
includeboth getting to the bathroom in time (due to
pain
DISEASE
and DOE) aswell as the sensation that she does not completely void. She hasno
dysuria
DISEASE
. The
swelling
DISEASE
in her legs is associated with mildincrease in
pain
DISEASE
and redness as well as itching. Her back
pain
DISEASE
has been worse..She was recently admitted to [**Hospital1 18**] cardiology service and d/c on[**2167-10-12**]. She was dx with
CHF
DISEASE
and her medication regimen wasadjusted..Cardiac ROS: She describes intermittent
chest pain
DISEASE
withactivity marked DOE with minimal activity positive orthopneaand PND and has a h/o claudication though
pain
DISEASE
is differentnow. She would intermittently hold her BP meds (ie metoprolol)b/c Admission Date: [**2183-10-2**] Discharge Date: [**2183-10-4**]Date of Birth: [**2115-3-22**] Sex: MService: MEDICINE
Allergies
DISEASE
:Sulfa (Sulfonamides) / Adhesive Tape / IodineAttending:[**Doctor Last Name 1857**]Chief Complaint:
Syncope
DISEASE
and
chest pain
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Mr. [**Known lastname 3311**] is a 68 yo man with a history of severe CAD s/p MI3V CABG (LIMA-LAD SVG-RCA sequential SVG-D1-OM) in [**2169**] andmultiple PCIs who presents with acute onset
chest pain
DISEASE
. Thepatient states that he was in his usual state of health when hewoke up this morning [**10-2**]. He was in his kitchen when the nextthing he knew he woke up on the floor. He denies any prodromeincluding
dizziness lightheadedness vertigo
DISEASE
focal weaknessor aura. He does not know how long he was unconscious but whenhe awoke he was experiencing acute onset [**10-8**] retrosternal
chest pain
DISEASE
. The
pain
DISEASE
was diffuse and located at the midline. Itwas not positional and was not acutely associated with
nausea
DISEASE
or
vomiting
DISEASE
. It did radiate up to his jaw which alarmed him sincethis was exactly what he experienced when he had his MI. He doesnot think he fell on his chest. He was able to get up on hisown climb the stairs and call EMS.He was brought to [**Hospital3 **] where he was given ASA andnitro SL without relief of his
chest pain
DISEASE
. He was started on aTNG drip but still complained of [**10-8**]
pain
DISEASE
. EKG showedventricularly paced rhythm with no acute ST or QRS changes fromprior. A Troponin-I measurment was 0.14. Myoglobin was 103. HisINR was 4.3. An ABG on 2L NC at that time was 7.32/46/95/24/Sat97%. He was subsequently transferred to [**Hospital1 18**] for possiblecatheterization.On review of symptoms he denies any prior history of
stroke
DISEASE
TIA
DISEASE
deep
venous thrombosis pulmonary embolism bleeding
DISEASE
at thetime of surgery
cough hemoptysis
DISEASE
black stools or red stools.He denies recent
fevers chills
DISEASE
or
rigors
DISEASE
. He is unable to walkvery far due to
left leg pain
DISEASE
but states this is due to anestablished
neuropathy
DISEASE
. All of the other review of systems werenegative.Cardiac review of systems is notable for absence of
dyspnea
DISEASE
onexertion paroxysmal
nocturnal dyspnea orthopnea
DISEASE
ankle
edema
DISEASE
palpitations
DISEASE
.Past Medical History:-CAD s/p MI-CABG [**2169**] (LIMA-LAD SVG-RCA SVG-D1-OM)-Hypertension-Hyperlipidemia-Atrial
tachycardias
DISEASE
s/p ablation followed by atrial
fibrillation/flutter
DISEASE
with
AV nodal ablation s/p pacer [**2177
DISEASE
**] onwarfarin-Neuropathy-Gout-Depression and
anxiety
DISEASE
Social History:significant for the absence of current tobacco use (smoked fromage 16-46 at 1 ppd). There is no history of alcohol abuse.Family History:There is no family history of
premature coronary artery disease
DISEASE
or sudden death.Physical Exam:Gen: WDWN middle aged Caucasian male in NAD mild distressmildly diaphoretic. Oriented x3. Mood affect appropriate.Pleasant.VS: T 96.6 BP 126/77 HR 84 RR 21 O2 sat 100% on 5 L/min NCHEENT: NC/AT. Sclera anicteric. PERRL EOMI. Conjunctiva werepink no
pallor
DISEASE
or
cyanosis
DISEASE
of the oral mucosa.Neck: Supple with JVP of 7 cm. No
carotid bruits
DISEASE
.CV: PMI located in 5th intercostal space midclavicular line.RR normal rate. Normal S1 S2 no murmurs rubs or gallops.Chest: Pacemaker palpable in L upper chestAdmission Date: [**2119-10-2**] Discharge Date: [**2119-10-13**]Date of Birth: [**2043-5-9**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:LasixAttending:[**First Name3 (LF) 1267**]Chief Complaint:
Chest pain shortness of breath
DISEASE
Major Surgical or Invasive Procedure:[**2119-10-5**] Aortic Valve Replacement(21mm Porcine). Mitral ValveReplacement(29mm Porcine). Two Vessel Coronary Artery BypassGrafting utilizing the LIMA to LAD and vein graft to obtusemarginal.[**2119-10-2**] Cardiac CatheterizationHistory of Present Illness:Mr. [**Known lastname 3315**] is a 76 year old male with chronic diastolic
congestive heart failure(aortic stenosis mitral regurgitation
DISEASE
)and chronic
atrial fibrillation
DISEASE
who presented to outsidehospital with progressive
shortness of breath and chest pain
DISEASE
forthe last six months. He admits to occasional rest
pain
DISEASE
as well.During that admission he was found to be anemic and transfusedwith several units of PRBC's. Endoscopy found a nonbleeding AV
malformation
DISEASE
in the proximal duodenum. Given his above cardiacstatus he was transferred to the [**Hospital1 18**] for further evaluationand treatment.Past Medical History:-Coronary Artery Disease prior PCI-Aortic Stenosis-Mitral Regurgitation-Chronic
Diastolic Congestive Heart Failure
DISEASE
-Cerebrovascular Disease
DISEASE
prior
TIA
DISEASE
's s/p right carotid stents/p Right CEA-Hypertension-Dyslipidemia-Chronic
Atrial Fibrillaton
DISEASE
-Chronic Renal Insufficiency-COPD-Anemia-History of
GIB AV
DISEASE
Malformation(duodenum)-BPH s/p TURPSocial History:Lives alone. Quit tobacco about one months ago prior heavytobacco use. He denies ETOH.Family History:Father died at age 36 from MI.Physical Exam:Admit PE: 5'[**22**]Admission Date: [**2126-10-3**] Discharge Date: [**2126-10-12**]Service: MEDICINE
Allergies
DISEASE
:Penicillins / LopressorAttending:[**First Name3 (LF) 3326**]Chief Complaint:
hematemesis
DISEASE
Major Surgical or Invasive Procedure:EGD s/p sclerotherapyHistory of Present Illness:81y/o M with h/o
diverticular bleed
DISEASE
presented to ED with
melena
DISEASE
and BRBPR x1 day. Pt felt lightheaded but denied CP
palpitations
DISEASE
or
dyspnea
DISEASE
at rest. Admission Date: [**2110-5-21**] Discharge Date: [**2110-5-23**]Date of Birth: [**2050-3-18**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 425**]Chief Complaint:Lightheadedness slow pulseMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:Dr. [**Known lastname 3339**] is a 60 yoM with a history of myxomatous mitral
valve disease
DISEASE
s/p
annuloplasty '[**98**] paroxysmal atrial
DISEASE
fibrillation
DISEASE
currently on Dronedarone and Coumadin h/o
postoperative NSVT
DISEASE
s/p ICD placement and h/o nondilated
cardiomyopathy
DISEASE
with EF who presents with
lightheadedness
DISEASE
andnear-syncope in the context of recent
undefined illness
DISEASE
and
weight loss
DISEASE
..Pt reports history of 25lb
weight loss
DISEASE
in the past 6 weeks thathe attributes to losing his sense of taste due to his
Parkinson's
DISEASE
meds. He denies any further focal symptoms duringthis time frame. Then today he was not feeling well while atwork in the ED here at [**Hospital1 18**]. He had been feeling lightheadedall day. He went home then relates that he was laying on thecouch watching TV with his daughter and may have passed out forsome time the only thing he remembers is his daughter wakinghim up. He is unsure if he actually lost consciousness or not. Afamily member took his pulse and found him to be in the 20's sobrought him to the ED..There his vitals were hr 31 110/68 18 100%
RA
DISEASE
. He was foundto have elevated INR
hypokalemic
DISEASE
and repleted. EKG showing
sinus bradycardia
DISEASE
with
intermittent ventricular escape beats
DISEASE
andVpaced beats. He is admitted to CCU for pacer interrogation andmonitoring..ROS is positive as above and also with worsening posturalhypoTN which he ascribes to the Parkinson's meds and lost oftaste also attributed to Parkinson's meds.ROS is negative for f/c/ns CP SOB
diaphoresis cough
DISEASE
PND
orthopnea syncope
DISEASE
Past Medical History:1. Myxomatous
mitral valve disease
DISEASE
status post mitral valverepair with an annuloplasty ring at the [**Hospital 3340**] Clinic in[**2098**].2. Postoperative nonsustained VT status post single chamber[**Company 1543**] ICD generator changed in [**2108**].3.
Atrial fibrillation
DISEASE
was previously on Amiodarone but now onDronedarone and also Coumadin4. Nonischemic
dilated cardiomyopathy
DISEASE
with an ejection fractionof 30-40%5.
Parkinson disease
DISEASE
recently initiated on Aricept andcarbidopa6. Progressive
orthostasis
DISEASE
with
dizziness
DISEASE
upon standing.7. Small
ASD
DISEASE
or
PFO
DISEASE
not felt to be clinically significantSocial History:Lives at home with wife and two daughters[**Name (NI) 1139**] Use: Never smokerAlcohol Abuse: No history of
alcohol abuse
DISEASE
.No drugsFamily History:
FH
DISEASE
:h/o colon CAPhysical Exam:96.5 72 116/74 15 99%
RA
DISEASE
Pleasant middle aged male in no distress good historian.JVD not elevated no hepatojugular reflux notedLungs CTAB no w/c/r/r good air movement no accessory muscleuse breathing comfortably on room airRRR no murmurs appreciated heart sounds soft S1 S2 no S3 S4Abd obese NT NDNo BLE edema noted but hyperpigmented macules noted2Admission Date: [**2196-4-23**] Discharge Date: [**2196-6-14**]Service:HISTORY OF PRESENT ILLNESS: The patient is a 78 year-oldmale admitted earlier then anticipated because of
failure
DISEASE
tothrive
respiratory difficulties peripheral edema
DISEASE
and
pericardial effusion
DISEASE
after having been discharged for a priorhospitalization for aspiration
pneumonia
DISEASE
where he was foundto have a collapse of his left main stem bronchus distaltrachea and right main stem bronchus for which hesubsequently had a stent placed during that previous visit.He returned on [**4-23**] of [**2195**] earlier then anticipated asmentioned previously for removal of these stents andtracheoplasty and pericardiotomy for intraoperativepericardiotomy for
pericardial effusion
DISEASE
that he developed.At the time of his admission the patient was afebrile withblood pressure 150/80 pulse 70 respiratory rate 20 and hewas sating 95% on room air. Notably on examination hiscardiac examination revealed an irregularly irregular rhythm.The lungs revealed bilateral crackles throughout and therewas 1 to 2Admission Date: [**2198-2-13**] Discharge Date: [**2198-2-20**]Service: SURGERY
Allergies
DISEASE
:ZestrilAttending:[**First Name3 (LF) 1481**]Chief Complaint:Lyphoma scheduled palliative splenectomyMajor Surgical or Invasive Procedure:Open splenectomyHistory of Present Illness:80 yo M with known
lymphoma
DISEASE
in need of splectomyPast Medical History:1.
Congestive Heart Failure
DISEASE
2.
HTN
DISEASE
3. s/p Tracheal reconstruction4.
Spinal stenosis
DISEASE
s/p laminectomy5.
Chronic Renal Failure
DISEASE
with baseline creatinine in mid 2's.6. BPH7. CAD s/p LAD PTCA in '[**91**]. Stress in [**2194**] with normal EF andfixed inferior perfusion defect.8.
Anemia
DISEASE
9 PAF not on anticoagulation10.
Depression
DISEASE
11.
OSA
DISEASE
Social History:Lives with his wife but son visits daily. Walks with walker atbaseline. Remote tobacco history. Drinks approximately 2 glassesof vodka per week.Family History:Non-contributoryPhysical Exam:(pre-op)96.4 120/50 82 24 94%RANAD age-appropriateHEENT: MMM minimal periorbital edeam ATNCCTA-B with decreased BS Admission Date: [**2163-2-22**] Discharge Date: [**2163-2-27**]Date of Birth: [**2086-12-13**] Sex: FService: MEDICINE
Allergies
DISEASE
:Sulfa (Sulfonamide Antibiotics) / Percocet / Lipitor / ZocorAttending:[**First Name3 (LF) 2291**]Chief Complaint:
fatigue anorexia
DISEASE
worsening
lung lesions
DISEASE
from imagingMajor Surgical or Invasive Procedure:Bronchoscopy with biopsy and BALPigtail catheter placement to treat iatrogenic
pneumothorax
DISEASE
History of Present Illness:76 year old female with h/o hypothyoidism HTN/HLP AAA repairin past with notable known lung adenoCA and new RLL lung masswhich has enlarged in size over the last 4 months beingfollowed by Dr. [**Last Name (STitle) **] in oncology who presented to
Dr.[**Name
DISEASE
(NI) 3371**]clinic today for follow-up of recent multiple ground glass
opacities
DISEASE
and recent biopsy of RL lung with c/o progressivenight sweats
anorexia weakness
DISEASE
. Pt is being admitted directlyfrom oncology clinic for further evaluation and inability tocare for herself at home secondary to
weakness
DISEASE
. Notable resultsfrom recent biopsy revealed new squamous cell CA (different thanprior adenoCA)..Regarding the patient's symptoms - noted last seen by Dr. [**Last Name (STitle) **]3wks prior - with progressive symptoms of
fatigue
DISEASE
wt loss (10lb past 6 mo) NS decreasing BP with PCP down titrating BP medsrecently. Overall symptoms had started [**4-10**] mo ago withrhinorrea
dry cough
DISEASE
ear
pain
DISEASE
all without
fevers
DISEASE
- tx withseveral courses of azithromycin/levofloxacin. In addition withprogressive
fatigue
DISEASE
- pt with further difficulty ambulating 50mmore due to gen decreased strength no focal symptoms does havemild DOE without SOB at rest productive cough/hemopytosis. Ptwith general mild
mid-lower back pain
DISEASE
without any current CPcomplaints presently. Pt denies any current ear
pain
DISEASE
HA or
sinus complaints
DISEASE
. Note patient has not taken any of her homemedication yet today at time of evaluation..ROS: Denies skin changes changes in
urination
DISEASE
or bowelsotherwise 10-point ROS is negative except as detailed above.Past Medical History:Onc PHMx:.1. Stage I
adenocarcinoma of the lung
DISEASE
1.5 cm in [**2154**] (stageIA).Did not receive adjuvant therapy.
Tumor
DISEASE
harbors had a KRASmutation and was EGFR wild-type.2. Multiple pulmonary ground glass
opacities
DISEASE
with indolentgrowthpattern (unclear etiology thought to be possible
adenocarcinomas
DISEASE
) since [**2154**].3. Stage I (T1c N0 M0) ER/PR positive HER-2/neu positive
breast cancer
DISEASE
of the left breast in [**2148**].4. Possible early stage
squamous cell carcinoma
DISEASE
of the lungdiagnosed on [**2163-2-11**] (growing right lower lobe lesion)..TREATMENTS:1. Status post adjuvant hormone therapy (tamoxifen) from [**2148**] to[**2150**] for her stage I
breast cancer
DISEASE
.2. Status post right lower lobe wedge resection in [**2155-1-27**].3. Status post erlotinib 150 mg/day from [**4-2**] to [**2156-4-22**](intolerant to medication due to grade [**2-6**]
rash
DISEASE
)..PMHx:.-
hypothyroidism
DISEASE
-
osteoporosis
DISEASE
-
HTN
DISEASE
- HLD- hiatal
hernia
DISEASE
and
GERD
DISEASE
-
AAA
DISEASE
s/p repair [**2132**] then [**2134**] with concurrent b/l fem-[**Doctor Last Name **]bypasses with complicated post-op course- h/o
peritonitis
DISEASE
[**2134**]- h/o SBO [**1-6**] abdominal adhesions in [**2132**]- s/p cholecystectomy [**2138**]-
depression
DISEASE
[**2153**]- Lung adenocarcinoma stage 1 s/p RLL wedge resection [**2154**] noadjuvant tx multiple pulm ground glass
opacities
DISEASE
with veryindolent growth pattern Admission Date: [**2189-2-18**] Discharge Date: [**2189-2-25**]Service: CCUHISTORY OF PRESENT ILLNESS: The patient is an 83-year-oldfemale with a past medical history significant for
coronary artery disease
DISEASE
congestive
heart failure hypertension
DISEASE
chronic
autoimmune hemolytic anemia
DISEASE
and history of a
gastrointestinal bleed
DISEASE
who presented to the EmergencyDepartment at [**Hospital1 69**] at 8 A.M.with
epigastric pain
DISEASE
. The patient's
pain
DISEASE
started atapproximately 7:30 A.M. on the day of admission after eatingbreakfast. It was described as a burning sensation. Thepatient took one sublingual nitroglycerin without effect.The patient reportedly denied any
shortness of breath
DISEASE
nausea vomiting fevers chills
DISEASE
or
headache
DISEASE
. The patienthad been off her aspirin and Plavix secondary to a
gastrointestinal bleed
DISEASE
in [**2188-12-26**] requiringhospitalization at [**Hospital3 1196**].Electrocardiogram obtained in the Emergency Department showedupsloping ST segments and was initially interpreted asJ-point elevation. Subsequently at 1 P.M. the patient'ssystolic blood pressures decreased to the 40s and repeatelectrocardiogram at that time revealed
bigeminy
DISEASE
with STelevations of 5 mm in V2 through V4. Cardiology team wasconsulted and the patient brought emergently to thecatheterization laboratory with systolic blood pressures inthe 80s.In the catheterization laboratory the patient's bloodpressure was marginal with pressures between 70s and 80ssystolic and dopamine drip was started. Initial angiogramshowed significant left anterior descending obstruction.Intra-aortic balloon pump was placed. The patient was thenelectively intubated as oxygen saturations were decreasingon non-rebreather mask. Arterial blood gas as that time wasa pH of 7.16 pCO2 of 51 and pO2 of 51.PAST MEDICAL HISTORY:1. Coronary artery disease status post left anteriordescending stent and percutaneous transluminal coronaryangioplasty to diagonal I and obtuse marginal I on [**2188-11-28**]2. Congestive heart failure3.
Hypertension
DISEASE
4. Chronic
autoimmune hemolytic anemia
DISEASE
5. History of a
gastrointestinal bleed
DISEASE
recently dischargedfrom the hospital on [**2189-2-10**]ALLERGIES: No known
drug allergies
DISEASE
.MEDICATIONS AT HOME: Enteric-coated aspirin 325 mg by mouthonce daily held since [**2-10**] Plavix 75 mg by mouth oncedaily held since [**2-14**] Synthroid 25 mcg by mouth oncedaily Zestril 5 mg by mouth once daily Lopressor 50 mg bymouth twice a day folate 1 mg by mouth once daily Protonix40 mg by mouth once daily Timoptic one drop to each eye oncedaily Xalatan one drop to each eye once daily prednisone 30mg by mouth once dailyPHYSICAL EXAMINATION: Vital signs: Temperature 98.8 bloodpressure 88/42 heart rate 122 respiratory rate 16 oxygensaturation 100% on 50% FIO2. In general the patient is anelderly white female sedated and intubated. Heart: Regularrate and rhythm positive S1 and S2 no murmurs gallops orrubs. Lungs: Bibasilar crackles. Abdomen: Softnontender nondistended normal active bowel sounds.Extremities: No
cyanosis clubbing
DISEASE
or
edema
DISEASE
right groin PAcatheter and arterial line in place left groin intra-aorticballoon pump in place.LABORATORY DATA: White blood cells 14.2 hematocrit 31.8platelets 283. Differential: Neutrophils 97% lymphs 3%.Sodium 142 potassium 3.4 chloride 106 bicarbonate 24 BUN23 creatinine 0.8 glucose 101. INR 1.1 PTT 20.6 PT 12.7.CK at 10 A.M. on [**2-18**] of 46 at 2 P.M. 475 with an MB of60 and an MB index of 12.6 and a troponin of 40.9.Urinalysis was benign. Chest x-ray showed heart size withinnormal limits a prominent pulmonary vasculature was notedbilateral
interstitial opacities
DISEASE
were noted.Electrocardiogram at 8:47 A.M. showed sinus at 87 beats perminute left axis deviation with left ventricular
hypertrophy
DISEASE
1 to [**Street Address(2) 1766**] elevations in V1 upsloping STelevations in V2 and V3 no ST depressions or Qs.Electrocardiogram at 1:05 P.M. with decreased blood pressureshowed
bigeminy
DISEASE
at 96 beats per minute [**Street Address(2) 1755**] elevations inV2 and V3 2 to [**Street Address(2) 2051**] elevations in V4 and V5 ST
depressions
DISEASE
in II III and AVF Q waves developed in V2through V5 with
loss of R
DISEASE
wave progression. Cardiaccatheterization from [**2189-2-18**] had the followingfindings: Left dominant system with three vessel coronary
artery disease
DISEASE
the left main coronary artery was normal theleft anterior descending was totally occluded at the site ofthe previously-placed proximal stent the ramus intermediusbranch had a long tubular 80% stenosis the left circumflexartery had a 50% proximal stenosis the first obtuse marginalbranch was totally occluded and the second obtuse marginalbranch had a 70% origin stenosis the left posteriordescending artery had a mild luminal irregularity the rightcoronary artery was a small non-dominant vessel and had an80% proximal stenosis. Successful percutaneous transluminalcoronary angioplasty of the proximal left anterior descending
in-stent lesion
DISEASE
and successful percutaneous transluminalcoronary angioplasty and stenting of the ramus intermediusbranch. Hemodynamic measurements performed after thecoronary intervention with the patient intubated requiringintravenous inotropic support with intra-aortic balloon pumpin the left femoral artery revealed elevated left-sidedfilling pressures. The wedge pressure was 21 mm Hg. Thecardiac index was marginally decreased at 2.1. As above anintra-aortic balloon pump was introduced into the leftfemoral artery.IMPRESSION: 82-year-old female with previous
coronary
artery disease
DISEASE
status post recent left anterior descendingstent
Class II congestive heart failure hypertension
DISEASE
history of recent
gastrointestinal bleed
DISEASE
presents with acuteST elevation anteroseptal and anterior wall myocardial
infarction
DISEASE
. Taken to the catheterization laboratory forintervention and admitted to the Coronary Care Unitintubated with an intra-aortic balloon pump in place aswell as on a dopamine drip secondary to
hypotension
DISEASE
.HOSPITAL COURSE BY SYSTEM:1. Cardiac:a. Ischemia: As above patient with proximal left anteriordescending stent in-stent
re-stenosis
DISEASE
as well as significantocclusion to the ramus intermedius status post intervention.The patient was started on aspirin and Plavixpost-intervention. Peak CK was noted to be 71 to 85 whichwas on [**2189-2-18**] which gradually trended down to avalue of 113 on the day of admission. In addition thepatient was started on an ACE inhibitor and beta blocker onceblood pressure could tolerate.
b.
DISEASE
Pump: As above patient noted to be in
cardiogenic shock
DISEASE
with increased wedge and decreased systolic blood pressure.Intra-aortic balloon pump was placed in the catheterizationlaboratory. The patient was also given lasix x 1 in thecatheterization laboratory for elevated wedge pressure anddiuresed well with this one-time dose. No additional lasixdoses were given on hospital day number one and greaterattention was paid to improving hemodynamics with pressor andinotropic agents. The patient was initially transferred tothe Coronary Care Unit on a dopamine drip however was notedto be markedly tachycardic to as high as 130s to 140s insinus rhythm. The decision was made to discontinue thedopamine and start milrinone for inotropic effect andLevophed for pressor support. The patient's blood pressurewas titrated to greater than 60 and the patient's heart ratesubsequently was better controlled in the 80s to 90s.Subsequently with improved hemodynamics decision was madeto remove the intra-aortic balloon pump on hospital daynumber three. In addition on the following day thepatient's milrinone and Levophed drips were discontinued asthe patient was maintaining adequate hemodynamics on her own.Lastly a decision of whether the patient should be long-termanticoagulated in light of her recent anterior wall event wasto be evaluated with an echocardiogram. Decision toanticoagulate long-term will be weighed against the possiblerisks in light of underlying gastrointestinal pathology and ahistory of a recent
gastrointestinal bleed
DISEASE
.c. Rhythm: Patient noted to have a
sinus tachycardia
DISEASE
onarrival to the Coronary Care Unit on a dopamine drip.Subsequently was switched to milrinone and Levophed drips.The patient's
sinus tachycardia
DISEASE
improved to normal sinusrhythm with occasional episodes of nonsustained ventricular
tachycardia
DISEASE
which was thought secondary to reperfusion.2. Pulmonary: Patient noted to be
hypercarbia
DISEASE
and hypoxicin the catheterization laboratory on a non-rebreather anddecision for intubation was made. The patient was maintainedon assist control on arrival to the Coronary Care Unit andsubsequently was weaned with successful extubation onhospital day number three.3. Hematology: Patient with a history of
chronic anemia
DISEASE
secondary to
chronic autoimmune hemolytic
DISEASE
etiologymaintained on prednisone as an outpatient. In light ofrecent events the patient was placed on stress dose steroidsthrough the intravenous which was subsequently changed tooral prednisone. The patient received two to three units ofpacked red blood cells while in the Coronary Care Unitsecondary to a slightly decreased hematocrit which wasthought secondary to her underlying chronic condition as wellas possibly secondary to her
gastrointestinal bleed
DISEASE
in lightof some coffee-ground
emesis
DISEASE
. The patient's hematocritremained relatively stable during her hospital stay with arange of 28 to 33.4. Gastrointestinal: As above patient with a history of a
gastrointestinal bleed
DISEASE
with one to two episodes ofcoffee-ground
emesis
DISEASE
while in the Coronary Care Unit. Coffeegrounds then cleared and the patient was maintained onProtonix 40 mg intravenously twice a day. As above thepatient's hematocrit remained stable for the most part duringher hospital stay and she remained hemodynamically stableand there was no need for Gastroenterology consult duringthis hospital stay.5. Renal: The patient's creatinine status post cardiaccatheterization remained at her baseline and there were noacute renal issues while an inpatient at [**Hospital1 346**].6. Fluids electrolytes and nutrition: Patient'selectrolytes were monitored closely with adequate repletionespecially in light of some
ventricular ectopy
DISEASE
noted ontelemetry. Initially nothing by mouth secondary tointubation and the patient was started on low-dose tubefeeds at 10 cc/hour ProMod with fiber. Upon extubationtube feeds were discontinued and the patient was advanced toan oral diet without complications.This has been a dictation detailing the hospital events from[**2189-2-18**] to [**2189-2-22**]. Addendum to followdetailing the rest of the [**Hospital 228**] hospital courseincluding a list of discharge diagnoses dischargemedications and plan for discharge and follow up. DR.[**Last Name (STitle) 2052**][**First Name3 (LF) 2053**] 12-462Dictated By:[**Name8 (MD) 2054**]MEDQUIST36D: [**2189-2-25**] 01:50T: [**2189-2-25**] 01:55JOB#: [**Job Number 2055**]Admission Date: [**2103-3-29**] Discharge Date: [**2103-4-10**]Date of Birth: [**2069-12-2**] Sex: MService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 3376**]Chief Complaint:
Chest pain
DISEASE
and
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Mr. [**Known lastname 2026**] is a 33 year old male who was transferred to [**Hospital1 18**]-EDon [**3-29**] after developing
chest pain
DISEASE
and
shortness of breath
DISEASE
acode blue was called while on [**Hospital Ward Name **] for out-patient CTscan. He is well known to the surgical service he has a pastmedical history significant for
sigmoid diverticulitis
DISEASE
s/plaparoscopic sigmoid colectomy. CT scan of chest demonstratedbilateral pulmonary emboli he was oxygenating well on nasalcannula an intravenous Heparin drip was started and he wastransferred to the ICU for close monitoring.Past Medical History:Past Surgical History:
Diverticulitis
DISEASE
Post-operative abdominal collectionPast Surgical History:[**2-28**] Laparoscopic sigmoid colectomy c/b anastomotic leak s/p[**Doctor Last Name 3379**] procedure
Umbilical hernia
DISEASE
repairSocial History:Smokes half a pack a day of tobacco. Alcohol rarely. No IV druguseFamily History:
HTN
DISEASE
and DMPhysical Exam:Upon admission:98.2 102 137/89 19 98% room airGen: No active distressHead/Eyes: Pupils equal and reactive to light extraocularmovements intactENT: Oropharynx clear no jugular venous distentionChest: Clear to auscultation bilaterallyCV: Regular rate tachycardicAbd: Soft non-distended Admission Date: [**2119-5-18**] Discharge Date: [**2119-5-27**]Date of Birth: [**2050-10-17**] Sex: MService: MEDICINE
Allergies
DISEASE
:Codeine / Heparin Agents / VancomycinAttending:[**First Name3 (LF) 905**]Chief Complaint:Tx for hypotension/
sepsis
DISEASE
Major Surgical or Invasive Procedure:Transesophageal echocardiogramHistory of Present Illness:Pt is a 68 yo male with DM HTN deep brain stimulator who isbeing transferred from the floor from
hypotension
DISEASE
. Pt says thathe has been having
fevers
DISEASE
off and on for 5 weeks. Max tempreached 104. No
weight loss
DISEASE
night sweats with this but pt doesendorses rigors/chills. He states that some nights he would have
fever
DISEASE
and sometimes his temperature would be 98.5 (
fevers
DISEASE
generally occured at night). Pt did not go to his [**First Name3 (LF) 3390**] until thispast Tuesday. Blood cultures were drawn and grew out GPC inclusters and pt was told to come to the ED. In the ED lactatewas 4.7 (attributed to
rigors
DISEASE
as lactate was lower previously)but patient did not meet strict criteria for
sepsis
DISEASE
then and wasadmitted to the floor and started on vancomycin.Past Medical History:1. DM 2 x 11 years2. Essential
tremor
DISEASE
followed by Dr [**Last Name (STitle) **] w/ DBS placed in [**2117**]3.
HTN
DISEASE
4.
melanoma
DISEASE
of ear 15 years ago5. h/o falls admitted in [**2115**]6. hypertTG leading to
pancreatitis
DISEASE
in [**2107**]7. ETOH
hepatitis
DISEASE
8. s/p CCY in [**2106**]9. h/o
peripheral neruopathy
DISEASE
10. hx of
CHF
DISEASE
11.
depression/anxiety
DISEASE
Social History:former physics instructor at [**University/College **]. Nonmarried no children. Liveswith sister in [**Name (NI) 745**]. No smoking. former heavy EtOH none now.Family History:Mother died of
pancreatitis
DISEASE
. Sister died of pancreatic cancerAdmission Date: [**2115-11-14**] Discharge Date: [**2115-11-16**]Date of Birth: [**2065-8-12**] Sex: FService: MEDICINE
Allergies
DISEASE
:Neosporin Scar Solution / adhesive bandageAttending:[**First Name3 (LF) 602**]Chief Complaint:
hyperglycemia
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Ms. [**Known lastname 3401**] is a 50 y.o. woman with
IDDM
DISEASE
c/b
retinopathy
DISEASE
and
proteinuria
DISEASE
on insulin pump (followed at [**Last Name (un) **] by Dr. [**First Name4 (NamePattern1) **][**Last Name (NamePattern1) 174**]) p/w
hyperglycemia
DISEASE
in setting of
emesis
DISEASE
and
diarrhea
DISEASE
x1D.Per pt she felt hyperglycemic at 5AM whe she noticed she wasurinating more frequently. At that time her FS in 300s (despitebeing within normal limits yesterday normally 100s-120s):subsequently 390 at 5am 400s after breakfast self-bolusedinsulin and continued to be in 400 all day when she decided tovisit her PCP. [**Name10 (NameIs) **] reports nonbloody
emesis
DISEASE
and nonbloody loosestools throughout the day and reports feeling dehydrated. Pt'slast meal was at 9pm yesterday. Denies fevers/chills current
nausea
DISEASE
or
abdominal pain
DISEASE
or
myalgias
DISEASE
. Reports
polyuria
DISEASE
but nopyuria/hematuria/dysuria. Denies any chest pain/pressure chestpalpiations radiating
pain
DISEASE
SOB
pleuritic pain
DISEASE
. Deniesepisodes of
diaphoresis
DISEASE
. No recent sick contacts unusual dietor recent travel. No recent changes in insulin or medications.No recent antibiotic use.In the ED initial VS T 100.4 HR 102 BP 111/42 RR 18 O2 99%
RA
DISEASE
. FS in triage was 452. Labs notable for lactate initially4.1 WBC 18 BS 406 Admission Date: [**2154-4-22**] Discharge Date: [**2154-4-27**]Date of Birth: [**2099-4-13**] Sex: MService: MEDICINE/[**Hospital1 212**]HISTORY OF THE PRESENT ILLNESS: The patient is a 55-year-oldmale with a history of
end-stage renal disease
DISEASE
onhemodialysis QMWF
hepatitis C hypertension
DISEASE
and
type 2 diabetes
DISEASE
who was recently admitted tothe [**Hospital6 256**] in [**2154-2-16**]with a question of
cellulitis
DISEASE
versus an
allergy
DISEASE
related tohis newly revised
AV fistula
DISEASE
.Recently the patient had begun to feel slightly out of theordinary about a week prior to presentation with some
fatigue
DISEASE
and
lethargy
DISEASE
initially without any
cough fever
DISEASE
or
chills
DISEASE
.Subsequently the patient developed some back and chestsoreness with achiness in the right chest with radiation tothe back. The patient did not go to his scheduledhemodialysis on Friday because he did not feel well.Instead he went to the [**Hospital3 **] Emergency Departmentwhere he had a CT and chest x-ray where he was diagnosed with
osteoarthritis
DISEASE
and discharged.The patient then went to hemodialysis the subsequent day. Hehad a temperature of 102 that night. Again the patientpresented to the [**Hospital3 **] Emergency Room where he had achest x-ray showing
pneumonia
DISEASE
. At that point the patientpreferred admission to the [**Hospital6 2018**] and presented to the Emergency Room on the same night.At this time the initial read of his chest x-ray showed noevidence of
pneumonia
DISEASE
and the patient was sent home with thediagnosis of costochondritis. Since this time which was on[**2154-4-21**] the patient has had increasing
lethargy
DISEASE
andawoke confused and
febrile
DISEASE
to 102 at which time again he wasbrought back to [**Hospital6 256**].PAST MEDICAL HISTORY:1. Type 2
diabetes
DISEASE
for the past 21 years complicated by
retinopathy nephropathy
DISEASE
.2. Hypertension.3. End-stage
renal disease
DISEASE
on hemodialysis since [**2153-9-16**]. AV fistula placed at outside hospital withsubsequent revisions times two.4. History of C.
difficile colitis
DISEASE
.5. Diverticulosis.6. Status post cholecystectomy.7. Hepatitis C.8. History of questionable
CHF
DISEASE
likely secondary to volume
overload
DISEASE
from ineffective dialysis.9. Cardiovascular: Echocardiogram in [**2154-1-16**] was alimited study EF greater than 55% mild symmetric
LVH
DISEASE
. Noknown
wall motion abnormalities
DISEASE
or
valvular disease
DISEASE
.10.
Parathyroid adenoma
DISEASE
in left lower pole of thyroid.MEDICATIONS AT THE TIME OF ADMISSION:1. Ecotrin 325 mg p.o. q.d.2. Insulin NPH 100 units per ml 35 units in the morning15-20 units subcutaneously every evening.3. Iron 325 mg p.o. q.d.4. Lipitor 40 mg p.o. q.d.5. Losartan 100 mg p.o. q.d.6. Metoprolol 150 mg b.i.d.7. Nephrocaps one p.o. q.d.8. Norvasc 5 mg p.o. q.d.9. Prilosec 20 mg p.o. q.d.10. Renagel 800 mg p.o. t.i.d.ALLERGIES: Cipro which causes mouth swelling.SOCIAL HISTORY: The patient lives at home with his wife. [**Name (NI) **]works as the [**State 350**] State Lottery however has notbeen working recently. Denied any history of tobaccoalcohol or IV drug use.PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature101.8 pulse 97 blood pressure 133/77 respirations 22pulse oximetry 66% on room air increased to 93% on a 50%face mask. General: Diaphoretic lethargic easilyarousable. HEENT: Anicteric. Pupils were equal andreactive to light. Mucous membranes
dry
DISEASE
. Neck: No
lymphadenopathy
DISEASE
JVD to 5 cm. Cardiovascular: Regular rateand rhythm normal S1 S2 II/VI systolic murmur at the base.Chest: Left mainly clear to auscultation except for slightcrackles at the base right with
decreased breath sounds
DISEASE
halfway up with E/A changes. Abdomen: Soft nontendernondistended positive bowel sounds no
hepatosplenomegaly
DISEASE
.No spider angiomata. Extremities: Warm no
edema
DISEASE
right bigtoe with 1 cm ellipsoid area of granulation tissue. Nofluctuants.LABORATORY DATA AT THE TIME OF ADMISSION: White blood cellcount 9.5 hematocrit 34.9 platelets 254000. Differential:Neutrophils 84.7% bands 0% lymphocytes 9.9% monocytes4.9% eosinophils 0.1% basophils 0.3%.Sodium 136 potassium 4.9 chloride 89 bicarbonate 28 BUN49 creatinine 8.9 glucose 110. Calcium 10.5 magnesium2.0 phosphorus 10.4.Chest x-ray: Rapid interval development of diffuseright-sided consolidation with tracheal shifting concerningfor collapse or plugging also with left upper lobeinfiltrates.EKG: Increased T waves in inferior leads in V6 ST slightlyincreased in lead V1.HOSPITAL COURSE: 1. PULMONARY: The patient initially wasadmitted to the Medical Intensive Care Unit given hisprofound
hypoxia
DISEASE
with a saturation of 66% on room air and hischest x-ray which showed rapid development within one day ofwhat was initially read as a small questionable left lowerlobe infiltrate on [**2154-4-21**] and a chest x-ray on [**2154-4-22**] with diffuse right-sided consolidation as well asleft upper lobe infiltrate.The patient was started on ceftriaxone and azithromycin. Hepersistently had a
dry cough
DISEASE
without any sputum. The patientwas initially on a 50% face mask at which time he desaturatedto the high 90s. He was changed to a nonrebreather.Subsequently on nonrebreather he had an ABG of 7.42 41 77.The patient was then weaned off oxygen from face mask tonasal cannula and had a requirement of approximately 5-6liters of oxygen. At this time he was transferred to themedical floor where he was rapidly weaned to a saturation of92% on room air. The patient was continued on a total of afive day course of azithromycin as well as a five day courseof IV ceftriaxone which was then changed to cefpodoxime/proxetil at 400 mg p.o. q.d. for an additional nine days tocomplete a total of a 14 day course.The patient had a repeat chest x-ray on [**2154-4-25**] thatshowed complete resolution of all of his prior infiltrates.The patient also had significant improvement in his lungexamination.2. HYPERTENSION: The patient was maintained on his homedose antihypertensive regimen with some initial holding ofhis Lopressor in the Intensive Care Unit which wassubsequently restarted on the floor secondary to his elevatedblood pressures.3. RENAL FAILURE: The patient was continued on his usualregimen of hemodialysis. Given his
hyperphosphatemia
DISEASE
thepatient was increased from 800 mg of Sevelamer p.o. t.i.d.with meals to 1600 mg p.o. t.i.d. with meals.4. RIGHT FOOT ULCER: Initially this was stable with nosigns of fluctuants or
infection
DISEASE
. The patient was seen bythe Podiatry Service and according to Podiatryrecommendations the patient was treated with b.i.d. to t.i.d.wet-to-dry dressing changes as well as antibiotic ointmentintermittently. The patient had his wounds debrided by hisattending physician on one to two occasions. The patientcontinued to have subsequent limitation in his mobilitysecondary to deconditioning as well as his right foot
ulcer
DISEASE
.The patient was seen by the Physical Therapy Service andrecommendations for transfer to a [**Hospital 3058**] rehabilitationfacility were made.5. DIABETES MELLITUS: The patient was continued on his homedose antidiabetic regimen with NPH and sliding scale insulinwith good glycemic control.6. DISPOSITION: The patient continued to have improvementfrom his initial pneumoniaAdmission Date: [**2154-6-2**] Discharge Date: [**2154-6-14**]Date of Birth: [**2099-4-13**] Sex: MService:HISTORY OF PRESENT ILLNESS: The patient is a 55 year-old manwith a history of diabetes/end
stage renal disease
DISEASE
onhemodialysis on the renal transplant list who presents with
fever
DISEASE
and
cough
DISEASE
. The patient was in his usual state ofhealth until the day of admission when he noticed increasingproductive
cough
DISEASE
increasing
shortness of breath
DISEASE
and somepleuritic
chest pain
DISEASE
. He denies
nausea vomiting diarrhea
DISEASE
substernal chest pain abdominal pain
DISEASE
. He did have some
diarrhea
DISEASE
but no
melena
DISEASE
or
hematochezia
DISEASE
. He denies
dysuria
DISEASE
or
hematuria
DISEASE
. Of note the patient also noticed right lowerextremity
edema
DISEASE
for the two days prior to admission. Hereports increasing
fatigue
DISEASE
. He denies
headache
DISEASE
visionchanges
nuchal rigidity
DISEASE
. The patient had a recent admissionon [**4-18**] with
pneumonia
DISEASE
treated with Ceftriaxone andAzithromycin and then oral Cefpodoxime on discharge.PAST MEDICAL HISTORY:1.
Diabetes mellitus
DISEASE
type 2.2. Hypertension.3. Hypercholesterolemia.4. End stage
renal disease
DISEASE
on hemodialysis preparing fortransplant.5. HCV.6. Ischemic right foot
ulcer
DISEASE
status post graft [**5-15**]. [**Doctor Last Name **] tothe posterior tibial.7. Diverticulosis.8. C-difficile [**11-16**].9. Laparoscopic cholecystectomy.10.
AV fistula
DISEASE
.11.
Hyperparathyroidism
DISEASE
ALLERGIES: Ciprofloxacin causes
mouth swelling
DISEASE
Levo -
rigors
DISEASE
MEDICATIONS ON ADMISSION:1. Metoprolol.2. Losartan.3. Atorvastatin.4. Protonix.5. Nephrocaps.6. Tylenol.7. Lipitor.8. Aspirin.9. Ibuprofen.10. Amlodipine.11. Sevelamer.12. Vancomycin.13. Ceftriaxone.PHYSICAL EXAMINATION: Temperature 99.7 heart rate 94 bloodpressure 160/88 respiratory rate 24 sating 82% on room air90% on a nonrebreather. In general the patient wassomnolent but arousable. HEENT pupils are equal round andreactive to light.
Extraocular movements
DISEASE
intact. Large
conjunctival hemorrhage
DISEASE
. Oropharynx is dry. Cardiovascular
holosystolic murmur
DISEASE
. Regular rate and rhythm. Lungsdecreased breath sounds to the left base. Abdomen positivebowel sounds soft nontender nondistended. Extremitiesleft fistula thrill right lower extremity edema. Right toe
necrotic
DISEASE
with
eschar
DISEASE
. No evidence of
cellulitis
DISEASE
or pus.LABORATORIES ON ADMISSION: White blood cell count 12.2hematocrit 39 platelets 293 83% neutrophils no bands 12lymphocytes 8.5 monocytes 1.9 eosinophils 4 basophils.Chest x-ray demonstrated a right lower lobe infiltrate.Electrocardiogram sinus at 62 normal axis normal intervalspeaked Ts in V2 left ventricular hypertrophy flat T wavelaterally no ST changes [**2154-5-10**]. No disease oncatheterization per report. No findings in computer. [**4-17**]echocardiogram EF 60% trace MR trace AI. [**5-15**] AK poplitealto posterior tibial.HOSPITAL COURSE: 1. Renal: The patient was continued ondialysis with management of volume status by the renalconsult team.2. Right toe
ischemia
DISEASE
: Vascular surgery was consultedimaged the right lower extremity. Once the patient's otherissues (see below) are resolved the patient was taken for aright great toe amputation by Dr. [**Last Name (STitle) **]. He was treatedwith perioperative broad spectrum antibiotics and will bedischarged to physical therapy rehab.3. Pulmonary: The patient was found to have a
pneumonia
DISEASE
inthe right lower lobe. He was monitored in the Intensive CareUnit for his
hypoxemia
DISEASE
. He was intubated on [**6-4**] for hypoxic
respiratory failure
DISEASE
. He was treated with Ceptaz Vancomycinand Azithromycin which was switched to Zosyn Azithromycinand Vancomycin until [**6-6**] when his regimen was switched toVancomycin and Ceftriaxone until [**6-7**] when Flagyl was added.At that time he required Dopamine for a drop in systolicblood pressure to the 80s after being given Levofloxacin. Hewas intubated approximately two days and then had an episodeof
hypertension
DISEASE
to 240 and
chest pain
DISEASE
. He ruled out for
myocardial infarction
DISEASE
and was started on antihypertensives.On [**6-5**] the patient underwent a bronchoscopy with BALdemonstrating no gross findings and 2Admission Date: [**2154-7-16**] Discharge Date: [**2154-7-17**]Date of Birth: [**2099-4-13**] Sex: MService: [**Location (un) 259**]HISTORY OF PRESENT ILLNESS: Fifty-five year old with malewith
end-stage renal disease
DISEASE
who is hemodialysis dependentwho at dialysis session aborted midway on [**Last Name (LF) 2974**] [**2154-7-12**] because he developed
chest pain
DISEASE
midway through dialysis.Per his wife he has had very frequent episodes of
chest pain
DISEASE
more than 10 during dialysis since he was started onhemodialysis in [**2153-8-16**]. He went to a hospital in[**Hospital1 392**] where he was started on nitrodrip. His
chest pain
DISEASE
resolved and has not returned since and he went home thenext day. His wife noted that the workup for his
chest pain
DISEASE
has been negative in the past including a cardiaccatheterization done in [**2153-9-16**] which showed normalcoronary arteries.Since the night prior to admission he has had
cough
DISEASE
. No
fevers
DISEASE
no
chills
DISEASE
. He missed dialysis today [**7-15**]because he was sent to the Emergency Department from homeshortly before he was scheduled for his 5 pm dialysis. Hedenies any changes in his diet or noncompliance with dietaryrestrictions. He has been unable to lie flat this past daydue to
shortness of breath
DISEASE
. This is new compared with hisbaseline. He does not complain of
shortness of breath
DISEASE
atrest currently and says that he is able to work but thathis exercise tolerance is markedly decreased compared withhis baseline. In the Emergency Department his oxygensaturation on room air is 80% so he was begun on anonrebreather mask.PAST MEDICAL HISTORY:1. Type 2
diabetes mellitus
DISEASE
for the past 21 years complicatedby
retinopathy
DISEASE
and
nephropathy
DISEASE
.2.
Hypertension
DISEASE
.3.
End-stage renal disease
DISEASE
on hemodialysis since [**2153-6-16**]. The patient has an
A-V fistula
DISEASE
placed at outsidehospital with subsequent revisions on two occasions. Thepatient undergoes dialysis Monday Wednesday [**Year (4 digits) 2974**] at SouthSuburban in [**Hospital1 392**].4. History of
Clostridium difficile colitis
DISEASE
.5. Diverticulosis.6. Status post cholecystectomy.7. Hepatitis C.8. History of questionable
congestive heart failure
DISEASE
likelysecondary to
volume overload
DISEASE
from an infected dialysis.9. Prior cardiovascular evaluation echocardiogram in [**2154-1-16**] was a limited study and showed an ejection fractionof greater than 55% mild symmetric left ventricular
hypertrophy
DISEASE
no known
wall motion abnormalities
DISEASE
or valvulardisease.10.
Parathyroid adenoma
DISEASE
in the left lower pole of thethyroid. He is scheduled for surgery on [**2154-8-2**].11. Status post right great toe amputation [**2154-6-12**].12. Status post right popliteal to posterior tibial arterybypass [**2154-5-15**].13. History of multiple
pneumonias
DISEASE
and recurrent
pneumonia
DISEASE
.14. Patient is scheduled to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of VascularSurgery for a right
carotid artery pseudoaneurysm
DISEASE
repair.MEDICATIONS ON ADMISSION:1. Hydralazine 50 mg qid.2. Clonidine patch 0.2 mg/hour one patch q Monday.3. Combivent inhaler two puffs qid.4. Cozaar 100 mg po q day.5. Heparin IV with dialysis.6. Lopressor 150 mg po bid.7. Multivitamin tablet one tablet po q day.8. Norvasc 10 mg one tablet po q day.9. Percocet 1-2 tablets po q4h prn
pain
DISEASE
.10. Protonix 40 mg po q day.11. Zocor 20 mg po bid.12. Folic acid one tablet po q day.13. Renagel two tablets po tid with meals.14. ASA 325 mg po q day.15. Insulin NPH 7 units subcutaneous q am.ALLERGIES: Ciprofloxacin causes mouth swelling but nodifficulty breathing.FAMILY HISTORY: Mother and father have a history of
diabetes
DISEASE
.SOCIAL HISTORY: Patient used to work for the State LotterySystem currently is unemployed. Lives in [**Location 38**] with hiswife and two children ages 17 and 20. He has never smoked.Denies alcohol use.REVIEW OF SYSTEMS: Patient notes chronic lower extremity
edema
DISEASE
right side greater than left side since his surgery[**2154-6-12**]. Patient reports that he is reasonablyambulatory at baseline.PHYSICAL EXAMINATION: Temperature 96.9 blood pressure186/67 respiratory rate 28 O2 saturation 94% onnonrebreather. General: Please middle-aged man appearingslightly
tachypneic
DISEASE
in no acute distress. HEENT: Pupils areequal round and reactive to light. Oropharynx with moistmucosal membranes no
erythema
DISEASE
and no lesions. Neck: 2 cmpulsatile mobile mass in the right mid cervical area suppleno
lymphadenopathy
DISEASE
. Chest: Breath sounds dull to half-wayup the posterior lung fields bilaterally with crackles at thetop of half-way up the lung fields also crackles in theright middle lobe area upper lobes are clear toauscultation. Heart: Regular rate and rhythm normal S1S2 no murmurs rubs or gallops. Abdomen is softnontender nondistended positive bowel sounds. Extremities:2Admission Date: [**2154-9-2**] Discharge Date: [**2154-9-5**]Date of Birth: [**2099-4-13**] Sex: MService:HISTORY OF PRESENT ILLNESS: The patient is a 55 year oldmale with a history of end state
renal disease
DISEASE
who wasadmitted from [**Hospital6 33**] on [**2154-8-31**] with
acute shortness of breath chest pain
DISEASE
and
hypoxia
DISEASE
. He wassaturating 70% on room air and was put on 100%non-rebreather and was transferred to [**Hospital1 190**] for further management.On arrival to [**Hospital1 69**] oxygensaturation was 40% on 100% non-rebreather. The patient thenwent into
cardiac and respiratory arrest
DISEASE
with
ventricular
DISEASE
tachycardia
DISEASE
. He underwent defibrillation three timesreceived amiodarone and was intubated and transferred to theMedical Intensive Care Unit.Potassium was 6.3 on admission and EKG revealed peaked Twaves. Chest x-ray showed
florid pulmonary edema
DISEASE
. He wasinitially placed on a Nitroglycerin drip given 4 mg ofmorphine one ampule of calcium gluconate 10 units ofinsulin intravenously with one ampule of D50 and Lasix 200 mgintravenously.The patient's wife reports that he does not comply with hisdiet. His two past episodes of
congestive heart failure
DISEASE
havebeen secondary to dietary noncompliance and difficultyadhering to his fluid restriction.In the Intensive Care Unit the patient had troponin peakingat 0.16 which was attributed to recent cardiacdefibrillation.The Renal Service got involved and dialyzed about two tothree liters off on [**9-2**]. The patient spiked a
fever
DISEASE
to101.0 F. on [**9-2**] with a urinalysis with six to tenwhite blood cells and moderate bacteria. Zosyn was started.A chest x-ray was questionable for aspiration
pneumonia
DISEASE
.During his Medical Intensive Care Unit stay the patient wastransiently on Dopamine which was attributed to sedation and
hypotension
DISEASE
with propofol. The patient self-extubatedhimself on [**9-3**] and has been stable from the hemodynamicand respiratory standpoint.PAST MEDICAL HISTORY:1. End-stage
renal disease
DISEASE
on hemodialysis. Dry weight of65 kilograms. The patient has a left sided arteriovenousgraft.2.
Diabetes mellitus
DISEASE
complicated by
nephropathy
DISEASE
and
retinopathy
DISEASE
.3. Congestive
heart failure
DISEASE
.4. Cardiac catheterization in [**2153**] negative for coronary
artery disease
DISEASE
.5.
Hypertension
DISEASE
.6. Echocardiogram in [**2154-6-16**] showing an ejectionfraction of 55% mild
atrial fibrillation
DISEASE
.7. Peripheral
vascular disease
DISEASE
status post right first toeamputation.8. Hepatitis C.9. History of recurrent
pneumonia
DISEASE
.10. Right popliteal tibial bypass one year ago.11. Diverticulosis.12.
Hyperparathyroidism
DISEASE
.13.
Dyslipidemia
DISEASE
.MEDICATIONS AT HOME:1. Metoprolol 150 twice a day.2. Folate 1 mg q. day.3. Prilosec 20 mg q. day.4. NPH 7 units q. a.m.5. Enteric-coated aspirin 325 q. day.6. Norvasc 10 mg q. day.7. Lipitor 40 mg q. h.s.8. Hydralazine 50 mg four times a day.9. Losartan 100 mg q. day.10. Nephrocaps one q. day.11. Renagel 800 mg three times a day.12. Trazodone 50 mg q. h.s.MEDICATIONS ON TRANSFER TO THE MEDICAL INTENSIVE CARE UNIT:[**Unit Number **]. Zosyn 2.25 mg intravenously three times a day.2. Tylenol p.r.n.3. Trazodone 50 mg q. h.s. p.r.n.4. Metoprolol 25 mg p.o. twice a day.5. Protonix 40 mg p.o. q. day.6. Savelamer 800 mg p.o. three times a day.7. Nephrocaps one q. day.8. Lipitor 40 q. day.9. Aspirin 325 mg q. day.10. Regular insulin sliding scale.11. Folate.SOCIAL HISTORY: The patient is married and lives with hiswife. [**Name (NI) **] tobacco no alcohol. Occasional cocaine use.FAMILY HISTORY: Noncontributory.PHYSICAL EXAMINATION: On transfer to the Medical IntensiveCare Unit revealed temperature maximum 101.8 F. temperaturecurrent 99.5 F.Admission Date: Discharge Date: [**2155-6-13**]Date of Birth: [**2099-4-13**] Sex: MService:PROCEDURES PERFORMED: Cadaver kidney transplant.ADMISSION DIAGNOSES:1.
Endstage renal disease
DISEASE
secondary to
diabetes mellitus
DISEASE
.2.
Peripheral vascular disease
DISEASE
.POSTOPERATIVE DIAGNOSES:1.
Endstage renal disease
DISEASE
secondary to
diabetes mellitus
DISEASE
.2.
Peripheral vascular disease
DISEASE
.HOSPITAL COURSE: Mr. [**Known lastname 3419**] is a 56-year-old male with
endstage renal disease
DISEASE
secondary to
diabetes mellitus
DISEASE
whoafter listing for cadaver kidney transplant an organ becomeavailable. He was taken to the operating room on [**2155-2-24**]where he underwent placement of a cadaver kidney in the leftiliac fossa. His posttransplant course was uncomplicated.The kidney began making urine almost immediately afterimplantation. He did not require dialysis in thepostoperative period. He was started with usual inductionimmunosuppression which includes 3 doses of Thymoglobulinfollowed by introduction of calcineurin inhibitors namelytacrolimus when the renal function improved. He alsoreceived steroid taper and CellCept. On postoperative day 2he was started on a clear liquid diet which was advanced tothe rest of his hospital stay. His [**Location (un) 1661**]-[**Location (un) 1662**] drain andFoley were removed on postoperative day 4 and onpostoperative day 5 he was certainly ready for discharge.He achieved a satisfactory prograf levels. Was able todemonstrate understanding and knowledge of hisimmunosuppression regimen after teaching from the transplantcoordinators. He was discharged home on [**2155-2-28**] and hewill follow up with the transplant service in 1 week. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **] [**MD Number(1) 3432**]Dictated By:[**Last Name (NamePattern4) 3433**]MEDQUIST36D: [**2155-6-13**] 08:48:39T: [**2155-6-13**] 10:53:16Job#: [**Job Number 3434**]Admission Date: [**2163-2-28**] Discharge Date: [**2163-3-7**]Date of Birth: [**2086-12-13**] Sex: FService: MEDICINE
Allergies
DISEASE
:Sulfa (Sulfonamide Antibiotics) / Percocet / Lipitor / Zocor /LevaquinAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:
fever
DISEASE
Major Surgical or Invasive Procedure:arterial lineHistory of Present Illness:76 year old female with h/o hypothyoidism HTN/HLP AAA repairin past with notable known lung adenoCA and new RLL lung masswhich has enlarged in size over the last 4 months beingfollowed by Dr. [**Last Name (STitle) **] in oncology was discharged yesterdayafter admission for bronchoscopy c/b
pneumothorax
DISEASE
for which apigtail was placed (removed at time of discharge). Tonight washome noted to have increased
cough
DISEASE
with rusty colored sputumand
fever
DISEASE
to 102. Also seemed to be more lethargic to familymembers. FSG 97 for EMS. Sats low 90's on 3L nc..ED Course: Initial Vitals/Trigger: 102 97/37 17 94% 6L nc.Chest xray notable for possible increased patchy
opacity
DISEASE
R lung.Labs notable for WBC 16.7 (N 82.2) Na 128 Creat 2.1 lactate0.9 Hct 29.2. UA wnl. Sputum blood and urine cultures sent.She was given 3L IVF NS and started on empiric IV abx coveragewith cefepime 1g vancomycin 1g and levofloxacin 750mg IV. Shereceived benadryl for extremity
erythema
DISEASE
and itching duringperi-administration with vancomycin - slowed rate of infusion aswell. She received tylenol for
fever
DISEASE
102 in the ED. IP fellowwas notified about re-presentation.Admission Vitals: 90 91/25 12 93% 5L nc. Access: 18G x2.Received 3L NS IVF..On arrival to the ICU pt is sedated secondary to benadryl (perdaughter) but easily arousable. Daughter says that mental statusimproved after IVF and abx administration in the ED withincreased
somnolence
DISEASE
after IV benadryl administration. Daughterand pt confirm the above story..Review of systems:(Admission Date: [**2100-9-3**] Discharge Date: [**2100-9-8**]Date of Birth: [**2024-9-1**] Sex: MService: NEUROLOGY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Last Name (NamePattern1) 1838**]Chief Complaint:R face and arm weaknessMajor Surgical or Invasive Procedure:IV TPAHistory of Present Illness:The patient is a 76 year old primarily-Cantonese speakingman with vascular risk factors who was in his usual state ofhealth until 8:30pm this evening. At that time while watchingTV he felt generally weak and unwell. He asked his wife to helphis to the bathroomAdmission Date: [**2112-12-8**] Discharge Date: [**2112-12-10**]Service: MEDICINE
Allergies
DISEASE
:SulfonamidesAttending:[**First Name3 (LF) 1850**]Chief Complaint:HypoxiaMajor Surgical or Invasive Procedure:noneHistory of Present Illness:82 yo F with CAD
CHF HTN
DISEASE
recent PE ([**10-17**]) who presents fromrehab with
hypoxia
DISEASE
and SOB despite Abx treatment for PNA x 3days. The patient was in rehab after being discharged from herefor PE. She was scheduled to be discharged on [**12-6**]Admission Date: [**2189-2-18**] Discharge Date: [**2189-2-26**]Service: CCUPlease note that this interval dictation takes up on [**2189-2-23**] where the dictation of Dr. [**First Name8 (NamePattern2) 1586**] [**Name (STitle) **] previouslydictated left off.ADDITIONAL HOSPITAL COURSE: The patient was transferred fromthe Coronary Care Unit to the floor at approximately 3 A.M.on [**2-23**] without event. At approximately 9 A.M. thepatient began to complain of
shortness of breath
DISEASE
and wasfound to be tachycardic to the 150s after walking a distanceto the bathroom. The patient's electrocardiogramdemonstrated
sinus tachycardia
DISEASE
with ST elevations in Leads V2and V3 otherwise the electrocardiogram was unchanged. Onexamination the patient had a blood pressure of 146/60pulse of 135 pulse oxygenation 98% on 2 liters wasdiffusely
wheezy
DISEASE
on respiratory examination and was markedlydiaphoretic without
jugular venous distention
DISEASE
or
edema
DISEASE
. Thepatient was given several doses of intravenous Lopressor aswell as high-dose intravenous lasix. The pulse oxygenationtransiently fell to 88% on 5 liters face mask and anarterial blood gas taken was 7.37/32/56. A chest x-raydemonstrated increased
congestive heart failure
DISEASE
and thepatient was given some nitro paste without effect and thenbegun on nitroglycerin drip as well as additional lasix 80 mgintravenous push.The patient rapidly thereafter clinically improved with ablood pressure falling from a high in the 170s/80s to 135/76with a normalization of respiratory rate and a pulseoxygenation of 92 to 95% on 6 liters as well as over a literof urine out ultimately and a clearing of previous
wheezing
DISEASE
on examination.The patient was again cycled with cardiac enzymes whichrevealed a troponin elevated greater than the measurablerange likely from the prior cardiac events that weredescribed in Dr.[**Name (NI) 2056**] dictation. However repeatedmeasurements of creatine kinase failed to demonstrate anelevation in that enzyme and rather demonstrated a continuedtrend down. The patient was begun on standing lasixinitially at 40 mg once daily which was then increased to 40mg twice a day and then to 80 mg by mouth twice a day. Thethought being that the patient had been approximately 4liters positive during this admission and that theabove-described events likely represented worsening
congestive heart failure/pulmonary edema
DISEASE
in the setting of
volume overload
DISEASE
. Additionally the patient's blood pressurewas better controlled with Captopril 12.5 mg by mouth threetimes a day and the patient's Lopressor dose as well wasincreased to 50 mg by mouth three times a day with goodeffect on the patient's cardiac rate.The patient's hematocrit continued to be stable for theremainder of this admission. She had no further respiratorydifficulties and was seen by Physical Therapy who suggestedinpatient therapy to improve the patient's endurance.The patient was sent for echocardiography which demonstratedan ejection fraction between 20 and 25% with multiple wallmotion abnormalities as described. In discussion with theCardiology team the decision was made not to anticoagulatethe patient at this time given her recent history ofsignificant clinical
gastrointestinal bleeding
DISEASE
. Inconsultation with the patient's attending cardiologistdecision was made to discharge the patient to rehabilitationon [**2189-2-25**].Please note that during the sequence described for [**2-23**]the patient's electrocardiogram appeared to show sinus
tachycardia
DISEASE
with the above-stated ST elevations in V2 and V3which did resolve with the patient's
tachycardia
DISEASE
.ADDITIONAL DATA: The patient was sent for echocardiographyon [**2-24**] with the following findings: Symmetric left
ventricular hypertrophy
DISEASE
with extensive regional systolicdysfunction consistent with
coronary artery disease
DISEASE
pulmonary artery systolic hypertension
DISEASE
moderate
mitral
regurgitation
DISEASE
mild
aortic regurgitation
DISEASE
. The leftventricular ejection fraction was estimated to be between 20and 25%. Left ventricular wall motion was noted in detailedreport to have abnormalities in the basal anterior portionwhich was hypokinetic mild mid-anterior which was
akinetic
DISEASE
basilar and anteroseptal which was
akinetic
DISEASE
mid-anteroseptalwhich was akinetic basal inferoseptal which was hypokineticmid-inferoseptal which was hypokinetic anterior apex whichwas akinetic septal apex which was akinetic inferior apexwhich was akinetic lateral apex which was
akinetic
DISEASE
and apexwhich was dyskinetic.DISCHARGE MEDICATIONS: Lasix 80 mg by mouth twice a dayCaptopril 12.5 mg by mouth three times a day Ambien 5 mg bymouth daily at bedtime as needed Prevacid 30 mg by mouthtwice a day Timoptic 5% one drop to both eyes once dailyXalatan one drop to both eyes once daily NPH four unitssubcutaneously twice a day regular insulin sliding scalefolate 1 mg by mouth once daily Synthroid 25 mcg by mouthonce daily Plavix 75 mg by mouth once daily for 25 days (tocomplete a one month course) Lopressor 50 mg by mouth threetimes a day and hold for systolic blood pressure less than orequal to 100 or pulse less than or equal to 60) aspirin 81mg by mouth once daily levofloxacin 250 mg by mouth oncedaily for five days (to complete a ten day course)prednisone 50 mg by mouth once daily for four days thenprednisone 40 mg by mouth once daily for four days thenprednisone 30 mg by mouth once daily (this is the patient'sbaseline prednisone dose for her
autoimmune hemolytic
DISEASE
anemia
DISEASE
).DISCHARGE DIAGNOSIS:1. Status post
myocardial infarction
DISEASE
2. Congestive
heart failure
DISEASE
3.
Hypertension
DISEASE
4. Chronic
autoimmune hemolytic anemia
DISEASE
5.
Gastrointestinal bleeding
DISEASE
DISCHARGE PLAN: The patient will be discharged torehabilitation. She is to follow up with her primary carephysician and cardiologist within one week of discharge fromrehabilitation as well as with her primaryhematologist/oncologist or other physician for follow up ofchronic
autoimmune hemolytic anemia
DISEASE
. The patient will becontinued on finger stick blood glucoses four times a daywith regular insulin sliding scale as described. It issuggested that the patient's electrolytes be measured everyother day and repleted as necessary.CONDITION ON DISCHARGE: Stable. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 2057**]Dictated By:[**Name8 (MD) 2058**]MEDQUIST36D: [**2189-2-25**] 02:31T: [**2189-2-25**] 02:38JOB#: [**Job Number 2059**]Admission Date: [**2139-1-14**] Discharge Date: [**2139-1-22**]Date of Birth: [**2059-5-5**] Sex: MService: SURGERY
Allergies
DISEASE
:Lisinopril / Aspirin Enteric CoatedAttending:[**First Name3 (LF) 974**]Chief Complaint:Abdominal Distention
Nausea
DISEASE
and
Vomiting
DISEASE
Major Surgical or Invasive Procedure:[**1-14**]:1. Lysis of single strand adhesion with derotation of a
volvulus
DISEASE
2. Placement of a nasogastric tube[**1-15**]: Second look laparotomyHistory of Present Illness:79M s/p repair of AAA [**1-31**] presents with
abdominal distention
DISEASE
nausea
DISEASE
and
vomiting
DISEASE
.Past Medical History:CAD (s/p CABG)
HTN
DISEASE
Admission Date: [**2140-8-19**] Discharge Date: [**2140-8-29**]Date of Birth: [**2058-12-14**] Sex: MService: MEDICINE
Allergies
DISEASE
:Sulfa(Sulfonamide Antibiotics) / Zocor / aspirinAttending:[**First Name3 (LF) 1253**]Chief Complaint:
Hypotension
DISEASE
Major Surgical or Invasive Procedure:[**2140-8-20**] OPERATIONS PERFORMED:1. Infrarenal
inferior vena cava
DISEASE
filter.2. Coil embolization of branches of the left hypogastric artery.History of Present Illness: This is an 81-year-old gentleman with a past medical history ofCAD s/p MI
MDS
DISEASE
on cycle 2 Vidaza
anemia
DISEASE
severe
COPD
DISEASE
baselinehome oxygen 2.5 L
hypertension
DISEASE
hyperlipidemiaalso with
bladder cancer
DISEASE
status post TURBT and BCG treatment in [**2135**]presenting with
retroperitoneal bleed
DISEASE
. He presented to [**Location (un) 620**]ED this afternoon with left sided
abdominal pain
DISEASE
radiating tohis left thigh. He had previously been hospitalized there from[**Date range (1) 3462**] for SOB and
tachycardia
DISEASE
during which he was found tohave a PE and PNA and discharged to rehab on lovenox bridge tocoumadin and levfloxacin. CT at [**Location (un) 620**] showed activeextravasation on CTA abd/pelvis. HCT 23.9 received 1U PRBC and10mg vitamin K and transferred to [**Hospital1 18**]..On arrival to the ED his VS were T 97.6 HR 122 bp 126/66 RR 20100% ON 5L NC. HCT at 24.3 from 30.5 on discharge [**2140-8-9**] (aftertransfusion). In ED Became
hypotensive
DISEASE
to 59/44 with 1U PRBCgiven 1 U FFP improving to 111/50 HR in 100s. ED EKG showed
sinus tachycardia
DISEASE
. Increasing
pain
DISEASE
Admission Date: [**2187-4-6**] Discharge Date: [**2187-4-10**]Date of Birth: [**2129-9-11**] Sex: FService: Medicine [**Hospital1 **] FirmHISTORY OF PRESENT ILLNESS: The patient is a 57-year-oldfemale with a history of
obesity
DISEASE
severe obstructive sleep
apnea pulmonary hypertension
DISEASE
and
diastolic congestive heart
failure
DISEASE
who was recently discharged from the hospital on[**3-23**] who returned for evaluation of persistent
nausea
DISEASE
and
headache
DISEASE
that has been progressive since discharge.She was admitted on [**3-19**] with
hypoxia
DISEASE
and started on[**Hospital1 **]-level positive airway pressure for
obstructive sleep apnea
DISEASE
in the hospital and discharged on [**3-23**] with home [**Hospital1 **]-levelpositive airway pressure at night. She reported mild
nausea
DISEASE
before discharge but reports progressive symptoms over thepast two weeks not associated with eating. The patientstates her symptoms seem worse when she was off the [**Hospital1 **]-levelpositive airway pressure machine. She was also complainingof a
headache
DISEASE
that is sometimes associated with
nausea
DISEASE
butnot always. She denies any other urinary symptoms. Shedenies
gastrointestinal complaints
DISEASE
such as
diarrhea
DISEASE
abdominal pain
DISEASE
or
constipation
DISEASE
. She denies any urinarycomplaints such a
dysuria
DISEASE
frequency or
hematuria
DISEASE
. No chest
pain
DISEASE
. No increase in her lower extremity
edema
DISEASE
. No increasein her baseline
shortness of breath
DISEASE
. She states her [**Hospital1 **]-levelpositive airway pressure has not been fitting well and sheuses it less than three to four hours per night.In the Emergency Room the patient was noted to be
hypertensive
DISEASE
with a systolic blood pressure of 214. She wasgiven 12 mg of Zofran 2 mg of Ativan and 4 mg of morphine.PAST MEDICAL HISTORY: 1. Hodgkin's diseaseAdmission Date: [**2161-9-21**] Discharge Date: [**2161-9-24**]Date of Birth: [**2128-11-1**] Sex: FService: [**Doctor Last Name **]CHIEF COMPLAINT: High blood pressure.HISTORY OF PRESENT ILLNESS: The patient is a 32-year-oldAfrican-American female with a history of
chronic headaches
DISEASE
obesity
DISEASE
and
hypertension
DISEASE
who is admitted from her primarycare physician's office for a blood pressure of 190/140. Shereports
intermittent headaches
DISEASE
for greater than one yearworsening in intensity over the last few weeks prior toadmission. The
headaches
DISEASE
typically start in the rightoccipital area move forward across the midline in thefrontal region. Extensive workup for
headaches
DISEASE
includinghead CT scan had been done all of which was unrevealing.Over the week prior to admission she reported worsening ofher
headache
DISEASE
general
malaise constipation
DISEASE
and decreased
urination
DISEASE
during the day but increased at night. She hadrecently stopped taking her atenolol which she began in[**Month (only) 956**] of this year because her blood pressure was withinthe normal range and she felt that stopping the medicationmight make her feel better with regards to her generalmalaise.Upon seeing her primary care physician for [**Name Initial (PRE) **] routine officevisit she was found to have a blood pressure of 190/140 with4Admission Date: [**2109-2-5**] Discharge Date: [**2109-2-18**]Date of Birth: [**2024-7-25**] Sex: MService: SURGERY
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 1481**]Chief Complaint:
Gastric adenocarcinoma
DISEASE
.Major Surgical or Invasive Procedure:Subtotal gastrectomy with J-tube placement.History of Present Illness:This is an 84 year-old male with a relatively early staged
stomach cancer
DISEASE
in the distal region. Work-up has been negativefor metastatic disease. He does have some lymph nodeenlargement in his mediastinum but those nodes were biopsynegative and FDG negative. He presented this admission forsubtotal gastrectomy. He has known significant
aortic stenosis
DISEASE
without symptoms. Thevalve area is quite tight at 0.8 sq cm but function ispreserved. Surgery was scheduled for [**2109-2-5**] with Dr.[**Last Name (STitle) **].Past Medical History:PMH: Iron deficiency
anemia
DISEASE
afib
borderline diabetes H Pylori
DISEASE
s/p treatment
PUD emphysema peripheral vascular disease
DISEASE
PSH
DISEASE
:1. Appendectomy2. Bilateral inguinal herniorrhaphy3. Right total hip4. Pacemaker insertionSocial History:Born in [**Location (un) 86**] lived in the same house in [**Location (un) 3493**] with hiswife for 50 [**Name2 (NI) 1686**]. Three grown sons living in [**Name (NI) 745**] [**Name (NI) 3494**]and [**Location (un) 3493**].Wife not visiting because she has a cold.Patient has housekeeper and landscaper at home.Retired insurance broker.He drinks occasionally.30-pack-year history of smoking stopped years ago.Family History:
Aneurysm
DISEASE
in mother and sister.[**Name (NI) 3495**] disease in father and brother.[**Name (NI) **]
cancer
DISEASE
history.Physical Exam:Discharge Physical Exam:VS: Temp 97.6F HR 60 BP 90/52 RR 18 SaO2 93%
RA
DISEASE
GEN: NAD AAOx3RESP: CTAB no wheezing/rhonchiCARD: RRRABD: Soft nontender nondistended normal bowel soundswell-healing midline incision no
erythema
DISEASE
or drainage J-tubein place with no surrounding
erythema
DISEASE
or drainageEXT: Warm well perfused no
peripheral edema
DISEASE
Pertinent Results:POST-OP DAY 1 LABS:[**2109-2-6**] 06:35AM BLOOD Hct-30.3*[**2109-2-6**] 06:35AM BLOOD Glucose-138* UreaN-27* Creat-1.1 Na-139K-5.1 Cl-107 HCO3-24 AnGap-13[**2109-2-6**] 06:35AM BLOOD Calcium-8.5 Phos-4.4 Mg-2.5.DAY OF ICU TRANSFER LABS:[**2109-2-10**] 06:19PM BLOOD WBC-5.1 RBC-2.72* Hgb-8.7* Hct-26.1*MCV-96 MCH-32.0 MCHC-33.4 RDW-14.2 Plt Ct-103*[**2109-2-10**] 06:19PM BLOOD Neuts-93* Bands-0 Lymphs-4* Monos-3 Eos-0Baso-0 Atyps-0 Metas-0 Myelos-0[**2109-2-10**] 06:19PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONALPoiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMALOvalocy-OCCASIONAL[**2109-2-10**] 06:19PM BLOOD PT-11.4 PTT-27.6 INR(PT)-1.1[**2109-2-10**] 06:19PM BLOOD Glucose-138* UreaN-23* Creat-0.9 Na-138K-5.1 Cl-109* HCO3-20* AnGap-14[**2109-2-10**] 06:19PM BLOOD CK(CPK)-78[**2109-2-10**] 06:19PM BLOOD CK-MB-2 cTropnT-Admission Date: [**2139-10-22**] Discharge Date: [**2139-10-26**]Date of Birth: [**2081-5-30**] Sex: FService: CARDIOTHORACIC SURGERYHISTORY OF PRESENT ILLNESS: This is a 58 year old femalepatient with known
aortic stenosis
DISEASE
and
aortic insufficiency
DISEASE
.Recent echocardiogram revealed a decreased in leftventricular function and she was referred to Dr. [**Last Name (STitle) **] foran aortic valve replacement. On [**2139-10-1**] she underwentcardiac catheterization which revealed normal coronaryarteries [**3-3**]Admission Date: [**2142-6-26**] Discharge Date: [**2142-7-6**]Date of Birth: [**2081-5-30**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:Sulfa (Sulfonamides)Attending:[**First Name3 (LF) 1267**]Chief Complaint:
Shortness of Breath
DISEASE
Major Surgical or Invasive Procedure:tPA therapyHistory of Present Illness:Ms [**Known lastname 3501**] is a 61 yo W s/p St. [**Male First Name (un) 923**] aortic valve replacement forsevere AI by Dr. [**Last Name (STitle) 2230**] in [**2138**] who presented to her PCP fivedays ago for annual checkup and for SOB. At that time she hadexperienced months of increasing SOB notable over the pastseveral weeks. Echo was obtained which showed
valve dysfunction
DISEASE
.She was thus taken to cath where fluoro demonstrated a St. [**Male First Name (un) 923**]aortic valve w/ one dysfunctional valve. She is transferred to[**Hospital1 18**] for further care.Past Medical History:Aortic Insuffiency s/p St. [**Male First Name (un) 923**] Aortic Valve Replacement in [**2138**]Asthma
Gout
DISEASE
Gastroesophageal Reflux Disease
DISEASE
s/p Lumbar Spinal Fusions/p Cholescystectomys/p Total Abdominal HysterectomySocial History:Married and lives w/husband. Nonsmoker for 20y. No EtOH.Disabled [**2-1**] back problems.Family History:Non-contributoryPhysical Exam:99.9 113/67 95 20 95RANADAdmission Date: [**2191-11-7**] Discharge Date: [**2191-11-25**]Date of Birth: [**2155-5-17**] Sex: MService: MED
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2641**]Chief Complaint:
Fevers cough
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:Patient is a 36 yo male with a history of
cerebral palsy
DISEASE
epilepsy
DISEASE
aspiration
aphasia
DISEASE
who was previously diagnosed withright lower lobe
pneumonia
DISEASE
on [**2191-10-5**] and completed a 10 daycourse of levofloxacin. However he was brought to ED by grouphome staff on [**2191-11-7**] with
fevers
DISEASE
to 101 and productive
cough
DISEASE
-unclear if white or yellow
phlegm
DISEASE
. The patient was
febrile
DISEASE
inthe ED with a WBC of 18.8 and placed on Levo/Flagyl foraspiration
pneumonia
DISEASE
with CXR showing persistent cavitary RLL
pneumonia
DISEASE
with effusion. He was found to have a
lung abscess
DISEASE
andtreated with IV Levo/Clinda.Past Medical History:
cerebral palsy
DISEASE
mental retardation
seizures
DISEASE
Social History:denies drugs EtOH tobaccoLives in group homeFamily History:noncontributoryPhysical Exam:TcAdmission Date: [**2194-7-20**] Discharge Date: [**2194-7-22**]Date of Birth: [**2155-5-17**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 398**]Chief Complaint:
Fever seizure
DISEASE
.Major Surgical or Invasive Procedure:NoneHistory of Present Illness:The patient is a 39 year old male baseline nonverbal withmental
retardation cerebal palsy seizure disorder
DISEASE
history ofrecurrent aspirations on a modified diet who presented to the EDon [**7-20**] from his [**Hospital **] nursing home with
seizure
DISEASE
x 2 on day ofpresentation ( 7 pm 8:15 pm) with a
fever
DISEASE
to 102. Status post
seizure
DISEASE
the patient was found to be hypoxic to 89% on
RA
DISEASE
perEMS report. His
seizure
DISEASE
spontaneously resolved. The patient hasa history of multiple aspirations in the past. [**Name (NI) **] HCPsister [**Name (NI) **] requested no central lines LP or femoral stick..In the ED a CXR was obtained which showed no evidence ofinfiltrate. His temperature in the ED was 103.8 for which he wasgiven tylenol. Given a concern for aspiration the patient wasgiven vanco 1 gm ceftriaxone 2 gm and flagyl. His pulse wasnoted to be up to 146 BP 152/98 and he was sat'ing 100Admission Date: [**2175-8-29**] Discharge Date: [**2175-9-2**]Date of Birth: [**2115-9-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Last Name (NamePattern1) 1167**]Chief Complaint:elective
hernia
DISEASE
reapirMajor Surgical or Invasive Procedure:right inguinal
hernia
DISEASE
repair
ventral hernia
DISEASE
repairHistory of Present Illness:Patient is a 59 yo M with non ischemic dilated CMF with EF of15-20% chronic A.fib
DM2
DISEASE
admitted for elective right inguinaland ventral
hernia
DISEASE
repain on [**8-29**] now transfered to the CCU for
hypotension
DISEASE
and
ARF
DISEASE
. Patient tolerated the operation withoutproblems but noted to have BP ranging 75-84/50-60s (pre-op105/60) post surgery. Patient was thought to be volume depletedand given total 1.5 L fluid however his BP remained low. Patientthen noted to have low urine output to 5 cc/hr over last fewhours. Cr rising from 1.4 to 3.9. CXR shows
cardiomegaly
DISEASE
Admission Date: [**2189-3-17**] Discharge Date: [**2189-3-25**]Service: CCUHISTORY OF PRESENT ILLNESS: The patient is an 83-year-oldwoman with a history of
coronary artery disease
DISEASE
with recentCCU stay and
autoimmune hemolytic anemia
DISEASE
who presented againto the CCU after being admitted to the floor with a two-dayhistory of weakness increased
shortness of breath
DISEASE
decreasedShe had stent to the left anterior descending at an outsidehospital in [**2188-11-25**]. She then represented to [**Hospital6 1760**] on [**2189-2-18**] with her
anginal
DISEASE
equivalent (
epigastric pain
DISEASE
) and was found to have STelevations on her electrocardiogram in leads V2-V5. She hada complicated emergent catheterization. The catheterizationplaced on Dopamine and intubated.On catheterization the patient had in stent
restenosis
DISEASE
ofthe left anterior descending and she received percutaneoustransluminal coronary angioplasty. A lesion of the ramusintermedius was stented as well. Intra-aortic balloon pumpwas initiated at that time.She had a four-day stay in the CCU when she was able to betaken off the balloon pump and ventilatory support. She didhave an episode of acute
hypoxia
DISEASE
after transfer to the floorthat improved with diuresis and nitrates. She was dischargedtwo weeks to this current admission to a nursing home.On presentation to the Emergency Department the patient had aheart rate of around 100 and systolic blood pressure in the80-90s. Hematocrit was down to 24.5. Hematocrit ondischarge from her prior hospitalization was 33Admission Date: [**2176-7-2**] Discharge Date: [**2176-7-7**]Date of Birth: [**2115-9-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 3513**]Chief Complaint:
Abdominal pain nausea and vomiting
DISEASE
.Major Surgical or Invasive Procedure:ERCP x 2.History of Present Illness:60 year-old male with history significant for severe nonischemic
hypertensive cardiomyopathy
DISEASE
(EF 20%) ICD placementdiabetes whopresents with
abdominal pain nausea
DISEASE
and
vomiting
DISEASE
since themorning of admission. The patient states he ate breakfast at 9am and approximately one hour later the
pain
DISEASE
began andcontinued to wax and wane throughout the day often reaching[**11-6**]. The
pain
DISEASE
was described as bandlike across his abdomenwithout radiation to the back. No aggravating factors other thaneating. The
pain
DISEASE
was alleviated with Morphine in the ED. Thepatient has never had this type of
pain
DISEASE
in the past. The patientalso complained of
nausea
DISEASE
and
vomiting
DISEASE
nonbilious/nonbloody.The patient denied
diarrhea melena
DISEASE
or
hematochezia
DISEASE
. He deniesany recent changes in his medications recent travel recentalcohol use history of
gallstones
DISEASE
or symptoms of
biliary colic
DISEASE
..In the ED the patient received one liter NS morphine and adose of levofloxacin. The patient was admitted to the MICU..In the MICU he was given NS at 150cc/hr. Antibiotics were notcontinued. The biliary team saw the patient and recommendedERCP. The procedure was deferred due to the patient's INR. Thepatient's
pain
DISEASE
was improved on transfer.Past Medical History:1.
Diabetes mellitus
DISEASE
type 2 insulin dependent x 8 years2.
Cardiomyopathy
DISEASE
EF 20%3. ICD placement4. Elevated transaminases unknown etiology5. Chronic
atrial fibrillation
DISEASE
6.
Chronic renal failure
DISEASE
most recent creatinine 1.77.
Umbilical hernia
DISEASE
repair [**8-/2175**]Social History:Lives with his wife has four grown children. Not currentlyworking on disability. Used to work in contruction. No tobaccoalcohol or illicits.Family History:No family history of
heart disease
DISEASE
.Physical Exam:VS: T 98.2 HR 74 BP 125/71 RR 18 O2sat 98%
RA
DISEASE
GEN: Awake lying flat in bed NAD well developedHEENT:
Atraumatic
DISEASE
mild
scleral icterus dry
DISEASE
mucosaNECK: No JVD no LADCV: Soft [**3-5**] holosystolic murmur LSB irregular rhythm regularrateLUNGS: CTA B/L w/ good inspiratory effortABD: Mildly distended soft tender to palpation in upperquadrants B/L and periumbilical. Negative [**Doctor Last Name **] sign noreboundEXT: Warm
dry
DISEASE
no LE
edema
DISEASE
NEURO: AAOX3 follows commands answers questions appropriatelyno focal deficitsPertinent Results:Labwork on admission:[**2176-7-2**] 08:20PM WBC-9.3 RBC-4.95 HGB-14.6 HCT-40.5 MCV-82MCH-29.5 MCHC-36.0* RDW-17.1*[**2176-7-2**] 08:20PM NEUTS-58 BANDS-0 LYMPHS-32 MONOS-8 EOS-2BASOS-0 ATYPS-0 METAS-0 MYELOS-0[**2176-7-2**] 08:20PM PLT SMR-NORMAL PLT COUNT-149*[**2176-7-2**] 08:20PM DIGOXIN-1.0[**2176-7-2**] 08:20PM TRIGLYCER-165*[**2176-7-2**] 08:20PM CK-MB-3 cTropnT-Admission Date: [**2176-12-28**] Discharge Date: [**2177-1-9**]Date of Birth: [**2115-9-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:UnasynAttending:[**First Name3 (LF) 689**]Chief Complaint:rectal
pain
DISEASE
Major Surgical or Invasive Procedure:central line placementarthrocentesisIncision and DrainageHistory of Present Illness:HPI: The patient is a 61 year old man with severe
systolic CHF
DISEASE
(EF 15-20%)
HTN DM2
DISEASE
who presents with
rectal pain
DISEASE
. He statesthat he has had 5 years of
intermittent rectal pain
DISEASE
following acolonscopy that diagnosed
internal hemorrhoids
DISEASE
. He states that 5days ago he had worsened rectal
pain
DISEASE
that was worsened with
bowel movements
DISEASE
. He has seen small amounts of blood in his stoolover this time. He was seen by his PCP 2 days ago who prescribedanusol. His
pain
DISEASE
progressed and was referred to the ED yesterdayby his PCP..In the ED his initial vitals were 98.8 85 144/83 18 94%RA. Arectal exam showed L glutteal area/perirectal area Admission Date: [**2177-2-20**] Discharge Date: [**2177-2-25**]Date of Birth: [**2115-9-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:UnasynAttending:[**First Name3 (LF) 898**]Chief Complaint:
Hypotension
DISEASE
AMSMajor Surgical or Invasive Procedure:NoneHistory of Present Illness: 61y/o M w/ DM2
CHF
DISEASE
s/p ICD CRI and
atrial fibrillation
DISEASE
presenting today with altered mental status and
hypotension
DISEASE
. Thepatient was recently admitted to [**Hospital1 18**] in mid-[**Month (only) 1096**] with a
perirectal abscess
DISEASE
complicated by
hypotension
DISEASE
and a MICUadmission. His course was further complicated by
renal failure
DISEASE
and a
transaminitis
DISEASE
attributed to unasyn therapy. He wasdischarged to a rehab facility on [**1-10**] and had recently leftthat facility and returned home last week. According to hiswife he has been more sedated since discharge from the hospitalbut otherwise has been doing relatively well at home. Heendorses chronic knee and LE
pain
DISEASE
but denies any recent CP SOB
abdominal pain N/V
DISEASE
poor PO intake progressive weakness
paresthesias
DISEASE
HA melena
DISEASE
or BRBPR. He has noticed someintermittant painless shaking in his hands that has occasionallycaused him to drop objects. He and his wife note good compliancewith his medications though she had held his coreg untilyesterday given slow HR at home. She feels that his alteredmental status can be directly attributed to the doses ofnarcotics that he was discharge on as this was a new medicationfor him. He has been eating well at home but did not take goodPO today despite receiving his regular dose of insulin..Today he presented to a neurology appointment for furtherevaluation of his hand shaking and there was noted to besomnolent. His blood pressure was in the 80s systolic and he wassent to the ED for further evaluation. There he was seen to bebradycardic to the low 50s and somnolent. His glucose level was33 and he received D50 and promptly awoke and was appropriateper report. His
bradycardia
DISEASE
was treated with atropine to whichhis HR increased to the 70s and his relative
hypotension
DISEASE
(systolic Admission Date: [**2179-5-13**] Discharge Date: [**2179-5-23**]Date of Birth: [**2115-9-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:UnasynAttending:[**First Name3 (LF) 3531**]Chief Complaint:arm
pain
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:Mr. [**Known lastname 3517**] is a 63yo M w/hx of
CHF
DISEASE
(EF 15-20%) s/p ICDplacement severe TR DM2 CKD (baseline Cr 1.3-1.8) afib oncoumadin elevated LFTs who presented to the ED with
chest pain
DISEASE
and L arm
pain
DISEASE
. By report of wife and patient he has had bad
gout
DISEASE
over the past several weeks to months. Principally thishas been involving his right foot limiting his ability to walk.In the past few days had increasing right arm
pain
DISEASE
that patientthought was also his
gout
DISEASE
. Then starting about yesterdaypatient had severe left arm
pain
DISEASE
at the shoulder and the elbow.This is ultimately what prompted him to come to the ED. ROSnotable for Admission Date: [**2180-4-25**] Discharge Date: [**2180-5-13**]Date of Birth: [**2115-9-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:Unasyn / OxycodoneAttending:[**Last Name (NamePattern1) 1167**]Chief Complaint:ICD firing
CHF
DISEASE
exacerbationMajor Surgical or Invasive Procedure:noneHistory of Present Illness:64 year old male with PMHx of severe
non-ischemic cardiomyopathy
DISEASE
with EF 25% s/p ICD placement [**2175**] mild-mod MR/TR DM ICD
Afib
DISEASE
on coumadin gout hypothyroidism CKD p/w vtach and ICDfiring. Last Wednesday he returned from [**Country 3515**] which is wherehe spends most of the year. He went to clinic to see Dr. [**First Name (STitle) 437**]day prior to admission and appeared volume overloaded admittedto running out of his prescriptions for at least 2 weeks. Healso had not been adhering to low salt diet. Amiodarone wasstarted in clinic for device discharges noted to have sevenepisodes of
VF
DISEASE
and
VT
DISEASE
on device check yesterday. This morninghis ICD fired again and was advised to go to ED. He felt no sxwhen his ICD fired butper report from wife he appeared to have
seizure
DISEASE
activity during this morning's
shock
DISEASE
..In the ED VS were 98.2 73 119/67 20 100%. He was noted to befluid overloaded on exam. Seen by EP in the ED who recommendedamiodarone loading for multiple episodes of
VT/VF
DISEASE
..On arrival to floor he complains of being tired. No chest
pain shortness of breath nausea vomiting
DISEASE
. His lowerextremities are swollen but he says this is stable. Also has
chronic orthopnea
DISEASE
..On review of systems he denies any prior history of
stroke
DISEASE
TIA
DISEASE
deep
venous thrombosis pulmonary embolism bleeding
DISEASE
at thetime of surgery
myalgias
DISEASE
joint pains cough hemoptysis
DISEASE
blackstools or red stools. He denies recent
fevers chills
DISEASE
or rigors.He denies
exertional buttock
DISEASE
or
calf pain
DISEASE
. All of the otherreview of systems were negative..Cardiac review of systems is notable for absence of
chest pain
DISEASE
dyspnea
DISEASE
on
exertion paroxysmal nocturnal dyspnea orthopnea
DISEASE
palpitations syncope
DISEASE
or
presyncope
DISEASE
.Past Medical History:
Nonischemic cardiomyopathy
DISEASE
LVEF 15-20%ICD placement for primary prevention of sudden
cardiac death
DISEASE
Diabetes mellitus
DISEASE
type 2 insulin dependent
Gout
DISEASE
Peripheral neuropathy
DISEASE
Chronic
atrial fibrillation
DISEASE
Chronic kidney disease
DISEASE
Elevated transaminases unknown etiology
Umbilical hernia
DISEASE
repair [**8-/2175**]
Gallstone pancreatitis
DISEASE
s/p ERCP ([**2176-6-28**])Internal hemorrhoidsHemoglobin C carrierSocial History:The patient is originally from [**Country 3515**] currently living with hiswife. Returned to [**Location 3515**] this past fall but came back to USafter severe
gout
DISEASE
flare of his foot. No smoking. He quitalcohol use no IV drug use. He says his diet is generallydifficult because hefeels like any food he eats causes
gout
DISEASE
flare.Family History:No first-degree relatives with
coronary artery disease
DISEASE
. Hismother had
breast cancer
DISEASE
..Physical Exam:Admission:VS: 99.9 112/69 76 20 97%
RA
DISEASE
GENERAL: obese M in NAD. Oriented x3. Mood affect appropriate.HEENT: NCAT. Sclera anicteric. PERRL EOMI. Conjunctiva werepink no pallor or
cyanosis
DISEASE
of the oral mucosa. No xanthalesma.NECK: Supple with JVD to level of mandible.CARDIAC: PMI located in 5th intercostal space midclavicularline. RR normal S1 S2. 2/6 systolic murmur no r/g. Nothrills lifts. No S3 or S4.LUNGS: No
chest wall deformities scoliosis
DISEASE
or
kyphosis
DISEASE
. Respwere unlabored no accessory muscle use. crackles at basesbilaterally wheezes or rhonchi.ABDOMEN: Soft NTND. No HSM or
tenderness
DISEASE
. Abd aorta notenlarged by palpation. No
abdominal bruits
DISEASE
.EXTREMITIES: Admission Date: [**2180-5-23**] Discharge Date: [**2180-5-27**]Date of Birth: [**2115-9-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:Unasyn / OxycodoneAttending:[**Last Name (NamePattern1) 1167**]Chief Complaint:
hypotension diarrhea
DISEASE
poor PO intakeMajor Surgical or Invasive Procedure:EJ placementSwan placementICU stayHistory of Present Illness:Pt is a 64 yo male PMHx significant for non-ischemic
cardiomyopathy
DISEASE
with EF 25% s/p ICD placement [**2175**] (v paced)mild-mod MR/TR DM ICD
Afib
DISEASE
on coumadin gout hypothyroidism
CKD
DISEASE
p/w vtach and ICD firing recently admitted for ICD firing
CHF
DISEASE
w/ EF 20-25%% who presents from
heart failure
DISEASE
clinicw/hypotension. Pt has presumed Cdiff w/ continued
diarrhea
DISEASE
vomitting and decreased PO intake w/ associated
dehydration
DISEASE
and
lethargy
DISEASE
at [**Hospital 100**] rehab facility d/c'ed from [**Hospital1 18**] Admission Date: [**2141-10-8**] Discharge Date: [**2141-10-17**]Service: MEDICINE
Allergies
DISEASE
:ValiumAttending:[**First Name3 (LF) 3544**]Chief Complaint:
hypoxia
DISEASE
Major Surgical or Invasive Procedure:PEG tube placementHistory of Present Illness:[**Age over 90 **] yo male with h/o
Parkinson's dz spinal compression fractures
DISEASE
and recent admission at [**Hospital1 **] from [**Date range (1) 3550**] for PNA who presentsfrom an OSH with PNA and stable
hypoxia
DISEASE
. On [**10-3**] he wasadmitted to OSH with worsening SOB. His sats were 89- 91% on a
NRB
DISEASE
and he was noted to be somnolent and in severe respiratorydistress. ABG was 7.30/60/88/29. CXR showed LLL infiltrate andwbc was 11.9. He was intubated and treated for suspected PNAwith
zosyn
DISEASE
and vancomycin at the OSH. He was ultimatelytransferred to the [**Hospital1 **] for continued care per request of thepatient's wife..In the MICU pt was continued on unasyn to complete 10 daycourse of antibiotics for his aspiration
pneumonia
DISEASE
. He waswitnessed to aspirate repeatedly leading to changes in mentalstatus and worsening
hypoxia
DISEASE
. This prompted the placement of aG-tube by GI on [**10-12**]. On [**10-13**] tube feeds were started pernutrition recs. Pt's respiratory status remained tenuous butstable and improved slowly every day. For decreased urineoutput he received several IVF boluses. He was then transferredto the medical [**Hospital1 **].Past Medical History:
Osteoporosis
DISEASE
Parkinson's Disease
DISEASE
T11-12
compression fracture
DISEASE
s/p laminectomy L4-5left LE
osteomyelitis
DISEASE
liver disease-granulomatous disease
DISEASE
LUE rotator tear
prostate CA-In
DISEASE
[**2126**] he had an orchiectomy for
prostate cancer
DISEASE
Social History:The patient has a sixty-pack-year history of tobacco. He quit in[**12/2098**]. He lives in a NH for the past 2 years. He is a retiredhistory professor. He reports no alcohol intake.Family History:Non-contributoryPhysical Exam:VS:Tc 96.2 HR 78 Bp 156/74 o2 sat 97% on 5 L NC RR 18Gen: chronically ill appearing elderly male in NADHEENT: anicteric mouth with thick yellow respiratory secretionsNEck:supple no JVDPulm: rhonchorus breath sounds throughout no cracklesCardio: difficult to hear heart sounds given diffuse rhonchiRRR no murmurs or gallopsAbd: soft NT ND Admission Date: [**2141-12-10**] Discharge Date: [**2141-12-21**]Service: MEDICINE
Allergies
DISEASE
:ValiumAttending:[**First Name3 (LF) 1148**]Chief Complaint:Transfer to [**Hospital1 18**] per wife request with
pneumonia
DISEASE
and
UTI
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:[**Age over 90 **] yo M with h/o
Parkinson's aspiration pneumonia
DISEASE
who presentedto [**Hospital1 **] ER from NH with acute SOB. He initially had
fever
DISEASE
to 102 axillary and
rigors
DISEASE
at his NH and was brought in by EMS.EN route to [**Hospital1 **] his RR was elevated and he presentedthere in
respiratory distress febrile
DISEASE
to 103 and
hypertensive
DISEASE
to 160s/100. They treated him with nebs and lasix and his respstatus improved. CXR revealed LLL infiltrate and U/A was grosslypositive with Admission Date: [**2142-4-23**] Discharge Date: [**2142-5-3**]Service: MEDICINE
Allergies
DISEASE
:ValiumAttending:[**First Name3 (LF) 3552**]Chief Complaint:SOB/altered mental status c/b hypercarbic
respiratory failure
DISEASE
Major Surgical or Invasive Procedure:PICCintubationHistory of Present Illness:As per MICU admission note patient is a [**Age over 90 **] yo male with h/oparkinsons and 3 prior admissions with aspiration
pneumonia
DISEASE
requiring intubation on episode in [**9-8**] s/p [**Date Range 282**] placement whopresents from his NH with decreased oxygen saturation andaltered mental status. History is obtained per NH/hospitalrecords. Per the patient's wife the Pt desatted to 82% 2 nightsPTA returning to normal in the AM prior to admission. Ptsubsequently desatted later in the day. Pt was placed on 02 byRT with good effect. [**Name (NI) 1094**] wife also reported low grade
fevers
DISEASE
toabout 99.7 (baseline 97.0). Per the NH notes the patient hasnot had a
cough
DISEASE
but has been productive of thick clear sputum.In addition he has also been more somnolent than normalspeaking less than usual. Of note the patient's wife reportedthat though the most recent speech and swallow evaluationrecomended nectar thickened liquids and ground solids he hasbeen eating a regular diet..In the ED the patient's vital signs were: T:99.4 HR:68 BP:161/83RR:24 SaO2:100% on 3L. CXR showed LLL infiltrate and UA waspositive. The patient was given 1G Vanco 500mg Levoflox 500mgflagyl sinemet x2 mirapex x1 and comptan x1..Within an hour after arrival to the floor the patient was notedto be somnolent and tired not responding to commands andappearing lethargic. ABG was performed showing a pH 7.22 pCO2104 pO2 146 HCO3 42. Given concerns for his
hypercarbic
DISEASE
respiratory failure
DISEASE
the patient was transferred to the MICU forurgent intubation..While in the MICU the patient was intubated for
hypercarbic
DISEASE
respiratory failure
DISEASE
and was been given vancomycin/zosyn to coverboth aspiration
pneumonia
DISEASE
and
urinary tract infection
DISEASE
. Mild
hypotension
DISEASE
with sedation..ROS: Done on admission: Admission Date: [**2142-5-21**] Discharge Date: [**2142-5-29**]Service: MEDICINE
Allergies
DISEASE
:ValiumAttending:[**First Name3 (LF) 3556**]Chief Complaint:mixed
respiratory failure
DISEASE
Major Surgical or Invasive Procedure:intubationHistory of Present Illness:[**Age over 90 **]yo man with h/o
Parkinson's disease
DISEASE
multiple prior admissionsfor aspiration
pneumonia
DISEASE
most recently [**2142-4-23**] who presentsagain from [**Hospital 100**] Rehab after the staff there had Admission Date: [**2189-3-17**] Discharge Date: [**2189-3-27**]Service: CCUADDENDUM:DISCHARGE MEDICATIONS: 1. Enalapril 15 po b.i.d. 2. Lasix40 po q.d. 3. Digoxin .125 po q.d. 4. Imdur 30 po q.d.5. Prednisone 10 po q.d. 6. Tylenol prn. 7. Prevacid 30po q.d. 8. Synthroid 250 micrograms po q day. 9. Aspirin325 mg po q.d. 10. Plavix 75 po q.d. for life. 11. Folate1 mg po q.d. 12. Timoptic .5 solution one drop each eyeq.d. 13. Zalatan .005% solution one drop each eye q.d. 14.Lopressor 50 mg po b.i.d. 15. Ambien 5 po q.h.s. prn. 16.NPH 4 units b.i.d. and then regular insulin sliding scale.17. K-Dur 10 mg po q.d.DISCHARGE INSTRUCTIONS: The patient should have potassiumfollowed in a couple of days and monitored closely and herpotassium dose adjusted as needed. She should have dailyweights and monitored for signs of
congestive heart failure
DISEASE
.The patient should follow up with
Congestive Heart Failure
DISEASE
Clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2067**] in one week. The phone number is[**Medical Record Number 2068**]. She should also follow up with her primary carephysician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] in one week as well. [**Last Name (LF) 1870**][**First Name3 (LF) **] 12.953Dictated By:[**Name8 (MD) 2069**]
MEDQUIST36D: [**2189-3-27**] 13:26T: [**2189-3-27**] 13:45JOB#: [**Job Number 2070**]111RAdmission Date: [**2142-7-13**] Discharge Date: [**2142-7-19**]Service: MEDICINE
Allergies
DISEASE
:ValiumAttending:[**First Name3 (LF) 3561**]Chief Complaint:-Unresponsive-Mental status changesMajor Surgical or Invasive Procedure:-Tracheostomy-Femoral Line-[**First Name3 (LF) 282**] tube changeHistory of Present Illness:Mr. [**Known lastname **] is a [**Age over 90 **]-year-old gentleman with history of[**Last Name (un) 3562**] Disease several aspiration events multipleadmissions for
respiratory distress
DISEASE
who was sent from [**Hospital 100**]rehab for evaluation after being found unresponsive at 3 PM. Perreport patient was found to open eyes but otherwise notresponding to verbal commands. ABG done at rehab showed marked
hypercarbia
DISEASE
(pCO2 100) and patient was referred urgently to theED..In the Emergency Department patient was intubated for presumed
hypercarbic respiratory failure
DISEASE
. ABG was not done on admission.CXR did not show any acute changes from ED visit 3 days prior(he had presented to ED on [**2142-7-10**] with
dyspnea
DISEASE
respiratorystatus had returned to baseline CXR was unchanged and labs didnot reveal
leukocytosis
DISEASE
). He was given Vanc/Levo/Flagyl forpossible
sepsis
DISEASE
albuterol/atrovent for bronchodilation andmethylprednisolone for Admission Date: [**2143-6-24**] Discharge Date: [**2143-6-26**]Service: MEDICINE
Allergies
DISEASE
:ValiumAttending:[**First Name3 (LF) 330**]Chief Complaint:
Hemoptysis
DISEASE
Major Surgical or Invasive Procedure:Bronchoscopy[**First Name3 (LF) 282**] tube placementUpper endoscopyHistory of Present Illness:Mr. [**Known lastname **] is a [**Age over 90 **] year old gentleman resident of [**Hospital 100**] rehabMACU with history of [**Last Name (un) **] Disease several aspirationevents leading to multiple admissions for
respiratory distress
DISEASE
and culminating in a tracheostomy ([**7-/2142**]) now presenting with
bleeding
DISEASE
around tracheostomy site which started earlier today.Patient is accompanied by his wife who provides most of thehistory. Patient was in his otherwise good state of health untilyesterdayt when nursing noted he had approximately 20-30 cc ofblood tinged sputum. Patient again had some small amounts of
bloody tinged secretions
DISEASE
this morning and then had about [**1-6**] ofa cup of bright red blood. Patient was given two doses ofracemic epinephrine via trach and was transferred to [**Hospital1 18**] forfuther evaluation.Of note patient had a fall from the bed at MACU 1 week ago.Patient was sleeping and fell in his sleepAdmission Date: [**2145-4-13**] Discharge Date: [**2145-4-20**]Service: MEDICINE
Allergies
DISEASE
:ValiumAttending:[**First Name3 (LF) 2297**]Chief Complaint:s/p
cardiac arrest
DISEASE
Major Surgical or Invasive Procedure:Mechanical ventilationPlacement of a right subclavian vein lineBronchoscopy with bronchoalveolar lavagePlacement of an arterial linePlacement of dart catheter for
pneumothorax
DISEASE
and removalTrach exchangePICC line placement[**First Name3 (LF) 282**] replacementHistory of Present Illness:Mr. [**Known lastname **] is a [**Age over 90 **]yo M from [**Hospital 100**] Rehab baseline Alert andOrientedx3 h/o
Parkinson's s/p trach multiple
DISEASE
aspirationevents
HTN
DISEASE
who was having BM today at Rehab became cyanotic
pulseless
DISEASE
and recieved chest compressions. He was never shockedor given meds but had return of spontaneous circulation atrehab. On arrival to the ED he was put on vent for poor respeffort. Was making non-purposeful spont mvmts. EKG showed sinus
bradycardia
DISEASE
. Labs were unremarkable with a lactate of 2.0. Priorto leaving the ED he is following commands communicating withhis wife by motioning. He is complaining of
pain
DISEASE
in ribs. Alsoin the ED CT head preliminarily read as not acute intracranialprocess CXR with RUL and RML infiltrates c/w aspiration. He washemodynamically stable and cooling protocol was not initiated ashe was neurologically improving. No meds were given in ED exceptfor 1L NS.On arrival to the ICU we was responding to commands and c/oleft sided rib
pain
DISEASE
.Review of systems: Pt unable to answer extensive ROS at thistime.Past Medical History:1. h/o aspiration PNA - Tx with levo unasyn vanco/zosyn in thepast2. h/o aspiration s/p swallow eval with swallowing difficultys/p [**Hospital 282**] placement on [**10-9**] - pt continues to feed for pleasureat Heb Reb3. Parkinson's4.
Osteoporosis
DISEASE
5. T11/12 compression fx6. LLE osteomyelelitis as a child/Chronic
osteomyelitis
DISEASE
quiescent.7.
granulomatous liver disease
DISEASE
8. LUE rotator cuff tear9.
Prostate cancer
DISEASE
s/p orchiectomy in [**2126**]10. s/p laminectomy L4-511.
Cataracts
DISEASE
s/p surgery[**46**].
Glaucoma
DISEASE
13.
Hypertension
DISEASE
14. Pt s/p recent tx for pseudomonas and aspiration PNA at hebreb15. s/p Trach with night ventilator support.16. s/p wrist fx17. chronic
constipation
DISEASE
18. Chronic abd pain- per Heb Reb notesSocial History:The patient has a sixty-pack-year history of tobacco. He quit in[**12/2098**]. He lives at [**Hospital **] rehab MACU for last 3 hrs. He is aretired history professor. [**First Name (Titles) **] [**Last Name (Titles) **] no alcohol intake.Family History:Non-contributoryPhysical Exam:Vitals: 96.4 49 110/52 22 99% on MMVGeneral Appearance: Thin elderly male interactive. Answerssimple questions follows commandsHead Ears Nose Throat: Normocephalic Poor dentitionsurgical left pupilCardiovascular: (S1: Normal) (S2: Normal). Bradycardic. NoMRG.Respiratory / Chest: (Expansion: Symmetric) [**Month (only) **] BS at rightbut o/w clear. ttp over left chest over ribsAbdominal: Soft tender. No guarding or rebound. Bowel soundspresent Not Distended. Area around G tube erythematous nopurulenceExtremities: Right lower extremity
edema
DISEASE
: Trace Left lowerextremity
edema
DISEASE
: TracePertinent Results:Admission laboratories:[**2145-4-13**] 03:00PM WBC-11.0 RBC-3.16* Hgb-9.8* Hct-30.6* MCV-97Plt Ct-441*[**2145-4-14**] 09:04AM Neuts-88.2* Lymphs-8.9* Monos-2.7 Eos-0.1Baso-0.2[**2145-4-13**] 03:00PM PT-13.4 PTT-26.0 INR(PT)-1.1[**2145-4-13**] 07:17PM Glucose-115 UreaN-23 Creat-0.7
Na-140
DISEASE
K-4.9Cl-104 HCO3-26[**2145-4-15**] 05:05AM ALT-1 AST-13 LD(LDH)-132 AlkPhos-53 TotBili-0.3[**2145-4-13**] 07:17PM Albumin-3.5 Calcium-9.1 Phos-3.3 Mg-2.1[**2145-4-13**] 03:00PM ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEGBarbitr-NEG Tricycl-NEGURINE:[**2145-4-14**] 12:30PM Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.021[**2145-4-14**] 12:30PM Blood-NEG Nitrite-NEG Protein-25 Glucose-NEGKetone-15 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG[**2145-4-14**] 12:30PM RBC-0 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2TransE-0-2[**2145-4-14**] 12:30PM CastHy-0-2-------MICRO:[**2145-4-13**] [**2145-4-15**] Sputum Cx:PSEUDOMONAS AERUGINOSACEFEPIME-------------- 8 S
CEFTAZIDIME-----------
DISEASE
8 SCIPROFLOXACIN--------- Admission Date: [**2145-7-31**] Discharge Date: [**2145-8-2**]Service: MEDICINE
Allergies
DISEASE
:ValiumAttending:[**First Name3 (LF) 2763**]Chief Complaint:Possible
GIB
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Mr. [**Known lastname **] is a [**Age over 90 **]yo M from
MACU
DISEASE
at [**Hospital 100**] Rehab baseline Alertand Orientedx3 h/o
Parkinson's s/p trach multiple
DISEASE
aspirationevents
HTN
DISEASE
and recent admission s/p possible arrest with cprcomplicated by PTX requiring chest tube now presenting fromrehab with dark output from his g-tube concerning for
GI bleed
DISEASE
.Per rehab records and patient's wife patient was in his USOH(sometimes confused but mostly oriented on vent at night withsettings: AC 500X10 FiO2 30% PEEP 5) until about 3 weeks agowhen he had some
bleeding
DISEASE
around his trach site thought [**1-5**]excessive suctioning. The
bleeding
DISEASE
persisted however solovenox (on for
DVT
DISEASE
ppx) was discontinued. The
bleeding
DISEASE
thenstopped but this am he was noted to have 200ML Admission Date: [**2146-7-15**] Discharge Date: [**2146-7-18**]Service: MEDICINE
Allergies
DISEASE
:ValiumAttending:[**First Name3 (LF) 594**]Chief Complaint:
abdominal pain
DISEASE
and distentionMajor Surgical or Invasive Procedure:noneHistory of Present Illness:[**Age over 90 **]yo from [**Hospital **] rehab with h/o
HTN
DISEASE
osteoperosis and chronicresp failure [**1-5**] to
parkinson's disease
DISEASE
trached and peged d/tmultiple aspiration events admitted for
abdominal distension
DISEASE
x 7days and LLQ
abdominal pain
DISEASE
..The patient has a several-year history of bowel difficultyattribtued to
parkinson's disease
DISEASE
and medication side-effect.Now he presents with 7 days of
abdominal distention
DISEASE
and
RLQ abdominal pain
DISEASE
relieved intermitently by
bowel movements
DISEASE
. Worseover last 2 days. No
emesis
DISEASE
or
fevers
DISEASE
. The patient has beenfollowed at [**Hospital **] rehab where KUB on [**7-13**] showed mildly
dilated
bowel
DISEASE
with increased gas. In [**Hospital **] rehab erythromycin wasstarted to promote peristalsis and a flexiseal was placed. Thepatient had a large black guiac neg BM on day of admission butcontinued to complain of abdominal discomfort..Of note on [**6-24**] was seen in [**Hospital1 **] ED for leg
pain
DISEASE
and
swelling
DISEASE
aswell as
abdominal pain
DISEASE
. HCT was baseline. LENI was neg for
DVT
DISEASE
.CT was initially read as unremarkable. Patient was d/c'ed torehab final read identified new left anterior iliac bone
fracture
DISEASE
. At rehab patient was noted to be in considerable
pain
DISEASE
and
grimacing
DISEASE
with minimal manipulations. He was given ultramfor
pain
DISEASE
control. He was initially on prophylactic lovenox butthis was d/c'ed after Hct of 23.2 on [**7-14**] down from 27.2 on [**7-12**]for which he recieved 1 unit of PRBC..On admission to ED VS were 99.7 60 129/46 20 99%. Labs showedUA leukocytes Admission Date: [**2146-8-20**] Discharge Date: [**2146-8-30**]Service: MEDICINE
Allergies
DISEASE
:ValiumAttending:[**First Name3 (LF) 3565**]Chief Complaint:
Hypotension
DISEASE
HypoxiaMajor Surgical or Invasive Procedure:Trach change [**8-21**] [**8-25**] [**8-26**]. [**Last Name (un) 295**] in place at time ofdischarge.Bronchoscopy [**8-21**]History of Present Illness:[**Age over 90 **]yo from [**Hospital **] rehab with h/o
HTN
DISEASE
osteoperosis and chronicresp failure [**1-5**] to
parkinson's disease
DISEASE
trached and peged d/tmultiple aspiration events brought to the ED from his NH withconcern for AMS. He had an unresponsive episode last night wasreportedly hypoxic (unclear degree). Staff at NH were alsoconcerned about possible facial droop. The wife rescinded theDNR order prior to arrival and stated he is to be full code. EMSsuctioned a golf ball sized mucous plug from his trach. He hashad episodes of mucus plugging in the past. Recenthospitalization for hip
fracture
DISEASE
and
ileus
DISEASE
. Urine culture from[**7-17**] grew resistant ecoli. He was started on a 7 day course ofceftriaxone on [**2146-7-18**]. Other micro history: urine w ESBL klebresistant ecoli pseudomonas resistant to
zosyn
DISEASE
in sputum andVRE swab..ED Course: Admission vitals at 0620 53 120/50 15 100. Code
stroke
DISEASE
called with concern for new facial droop. CT head wocontrast was negative for acute
intracranial hemorrhage
DISEASE
. Oncefamily arrived they confirmed that facial droop was old. Pt wasdocumented DNR but was reversed for transport. Family alsoclarified that code status is NO COMPRESSIONS but would wantepinephrine and similar drugs. Started ceftriaxone 1g forpresumed
UTI
DISEASE
. Briefly
hypotensive
DISEASE
to 80's at 7am got 1L IVF.Vitals prior to transfer: 121/53 55 13 100% on vent (FiO240% tidal volume 500 PEEP 5 rr 13). Access: 20g hand 22ghand 18 R forearm. Foley catheter from rehab not exchanged..On the floor pt c/o L
hip pain
DISEASE
.Past Medical History:1. h/o aspiration PNA - Tx with levo unasyn vanco/zosyn in thepast2. h/o aspiration s/p swallow eval with swallowing difficultys/p [**Date Range 282**] placement on [**10-9**] - pt continues to feed for pleasureat HebReb3.
Parkinson disease
DISEASE
4.
Osteoporosis
DISEASE
5. T11/12 compression fx6. LLE osteomyelelitis as a child/Chronic
osteomyelitis
DISEASE
quiescent.7.
granulomatous liver disease
DISEASE
8. LUE rotator cuff tear9.
Prostate cancer
DISEASE
s/p orchiectomy in [**2126**]10. s/p laminectomy L4-511.
Cataracts
DISEASE
s/p surgery[**46**].
Glaucoma
DISEASE
13.
Hypertension
DISEASE
14. h/o of treatment for pseudomonas and aspiration PNA at hebreb15. s/p Trach with night ventilator support.16. s/p wrist fx17. chronic
constipation
DISEASE
18. Chronic abd pain- per Heb Reb notes19. Recent admission following
vasovagal
DISEASE
event at
heb/reb
DISEASE
s/pchest compressions complicated by PTX s/p chest tube20. L ant pubic rami
fracture
DISEASE
L ant iliac
fracture
DISEASE
Social History:The patient has a sixty-pack-year history of tobacco. He quit in[**12/2098**]. He lives at [**Hospital **] rehab MACU for last 3 hrs. He is aretired history professor. [**First Name (Titles) **] [**Last Name (Titles) **] no alcohol intake.- Tobacco: none currently- Alcohol: none currently- Illicits: noneFamily History:Non-contributoryPhysical Exam:Admission Physical Exam:Vitals: T: 97.5 BP: 104/45 P:75 R:14 O2: 100% (FiO2 40% tidalvolume 500 PEEP 5)General: Alert elderly male trach on vent no acute distressHEENT: Sclera anicteric MMM oropharynx clearNeck: supple trach site intact no LADLungs: diffuse
wheezes and rhonchi
DISEASE
to auscultationCV: Regular rate and rhythm normal S1 Admission Date: [**2147-9-25**] Discharge Date: [**2147-9-29**]Service: MEDICINE
Allergies
DISEASE
:ValiumAttending:[**First Name3 (LF) 594**]Chief Complaint:Altered mental statusMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:[**Age over 90 **]M h/o
HTN
DISEASE
osteoperosis and chronic resp failure [**1-5**] to
parkinson's disease
DISEASE
trached and peged d/t multiple aspirationevents recent
pneumonia
DISEASE
and SIADH who was brought to the EDfrom his NH with concern for AMS. Per my discussion with hiswife over the last 10 days he has been less interactive andtoday has been moaning. At baseline the patient requiresextensive pulmonary toilet and today was noted to haveworsening secretions. No
fevers
DISEASE
documented in the rehabfacility. Additionally she reports that he has new abdominaldistension.In the ED initial VS were: 62 129/55 20 100%. He underwentCT head and CT abdomen. CT head did not show any acute process.CT abdomen shows a likely
infectious
DISEASE
process in the right lowerlobe concerning for necrotizine pneumonia. He also had a UAwith 129 WBC's few bacteria and large leukesterase. In the EDhe was started on vancomycin cefepime and flagyl. He was notedto be
hypotensive
DISEASE
but was not responsive to IVF resusitation.As a result he was placed on norepinepherine. Prior to transferto the floor his SBP was in the 120s.On arrival to the MICU the patient was unresponsive onventilator. Additional history or review of systems wereunobtainable.Past Medical History:1. h/o aspiration PNA - Tx with levo unasyn vanco/zosyn in thepast2. h/o aspiration s/p swallow eval with swallowing difficultys/p [**Month/Day (2) 282**] placement on [**10-10**] - pt continues to feed for pleasureat HebReb3.
Parkinson disease
DISEASE
4.
Osteoporosis
DISEASE
5. T11/12 compression fx6. LLE osteomyelelitis as a child/Chronic
osteomyelitis
DISEASE
quiescent.7.
granulomatous liver disease
DISEASE
8. LUE rotator cuff tear9.
Prostate cancer
DISEASE
s/p orchiectomy in [**2126**]10. s/p laminectomy L4-511.
Cataracts
DISEASE
s/p surgery[**46**].
Glaucoma
DISEASE
13.
Hypertension
DISEASE
14. h/o of treatment for pseudomonas and aspiration PNA at hebreb15. s/p Trach with night ventilator support.16. s/p wrist fx17. chronic
constipation
DISEASE
18. Chronic abd pain- per Heb Reb notes19. Recent admission following
vasovagal
DISEASE
event at
heb/reb
DISEASE
s/pchest compressions complicated by PTX s/p chest tube20. L ant pubic rami
fracture
DISEASE
L ant iliac
fracture
DISEASE
Social History:The patient has a sixty-pack-year history of tobacco. He quit in[**12/2098**]. He lives at [**Hospital **] rehab MACU for last 3 hrs. He is aretired history professor. [**First Name (Titles) **] [**Last Name (Titles) **] no alcohol intake.- Tobacco: none currently- Alcohol: none currently- Illicits: noneFamily History:Non-contributoryPhysical Exam:ADMISSION PHYSICAL
EXAM
DISEASE
General: unresponsive trached on ventilatorHEENT: Sclera anicteric MMM left pupil 4mm right pupul 2mmNeck: suppleCV: RRR normal S1 Admission Date: [**2127-9-20**] Discharge Date: [**2127-9-30**]Date of Birth: [**2077-7-23**] Sex: FService: NEUROSURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1271**]Chief Complaint:Left Occipital Epidural
Hematoma
DISEASE
Major Surgical or Invasive Procedure:Evacuation of left occipital epidural
hematoma
DISEASE
History of Present Illness:50yo WF with PMH significant for
cervical disc herniation
DISEASE
that presented to outside neurosurgeon 2-2.5 weeks ago forevaluation. Following that appointment for which no interventionwas pursued patient started to have episodes of falling to theground with any attempt at standing up. Patient denied HA
seizure
DISEASE
activity/symptoms LOC or lightheadedness with eachepisode simply stating that Admission Date: [**2182-6-23**] Discharge Date: [**2182-6-28**]Date of Birth: [**2119-7-11**] Sex: FService: MEDICINE
Allergies
DISEASE
:Atenolol / VasotecAttending:[**First Name3 (LF) 3574**]Chief Complaint:Mental status changesMajor Surgical or Invasive Procedure:noneHistory of Present Illness:62 yo F with h/o
HTN hypertensive heart disease
DISEASE
who presentswith two days of
fever nausea vomiting
DISEASE
and mental statuschanges. Patient is confused and has poor insight into herrecent symptoms and reasons for presentation to the hospital. Admission Date: [**2130-6-13**] Discharge Date: [**2130-6-16**]Date of Birth: [**2068-8-5**] Sex: FService: NEUROSURGERY
Allergies
DISEASE
:Ciprofloxacin / Sulfa (Sulfonamide Antibiotics)Attending:[**First Name3 (LF) 1271**]Chief Complaint:CC:[**CC Contact Info 3582**]Major Surgical or Invasive Procedure:noneHistory of Present Illness:HPI:61yo female from OSH who was found at the bottom of astaircase approximately 2.5hrs ago. EMS called and pttransported to [**Hospital3 3583**]. At scene pt noted to be awakeand alert.
GCS
DISEASE
at [**Hospital3 3583**] 6. Intubated at approx. 18:40Past Medical History:PMHx:
Seizure disorder
DISEASE
Admission Date: [**2146-7-1**] Discharge Date: [**2146-7-4**]Date of Birth: [**2088-9-20**] Sex: MService: [**Hospital Unit Name 196**]
Allergies
DISEASE
:Percocet / ShellfishAttending:[**First Name3 (LF) 2071**]Chief Complaint:
Chest Pain
DISEASE
Major Surgical or Invasive Procedure:Cardiac CatheterizationHistory of Present Illness:57M h/o
HTN hypercholesterolemia
DISEASE
AAA PVD CAD who presentedto OSH with SSCP [**8-28**] radiating the left arm and back startingat 4am on the morning PTA. He also had
diaphoresis vomiting
DISEASE
SOB w/ wheezes. At OSH he received NTG ativan fentanyl andmorphine without sig relief. Was also give lasix lopressor andstarted on plavix nitro gtt and heparin gtt. CTA was neg forPE. ECG showed ST
depressions
DISEASE
in V1-V3 inferior ST elevation.Past Medical History:1.
arthritis
DISEASE
2.
intermittent claudication
DISEASE
3.
HTN
DISEASE
4.
hypercholesterolemia
DISEASE
5. barrett's esophagus6.
renal calculi
DISEASE
7. CAD8. AAA9.s/p abodominal hernia repair10.cholecystectomy[**52**]. shoulder surgery[**53**]. remote
seizure
DISEASE
Social History:smokes 1 pack/day since age 16occasional ETOHlives with wive and daughterFamily History:
HTN
DISEASE
No known early MI/CAD.Physical Exam:VS - T98.3 P83 R12 BP111/68 97%RAGen - drowsy but arousableHEENT - anicteric no
conjunctival pallor
DISEASE
no oral findings noLAD neck suppleCV - RRR nml S1/S2 no M/G/R. No JVD.Resp- CTAB.
Snoring
DISEASE
loudly. No incr WOB.GI - Pos BS S/NT/ND. No HSM/Masses.Neuro - Sleepy but arousable. PERRL. EOMI. Withdraws all ext.Strength V/V.Ext - No C/C/E.Pertinent Results:[**2146-7-1**] 11:55PM GLUCOSE-97 UREA N-16 CREAT-1.0 SODIUM-142POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-30* ANION GAP-11[**2146-7-1**] 11:55PM CK(CPK)-159[**2146-7-1**] 11:55PM CK-MB-8 cTropnT-0.23*[**2146-7-1**] 11:55PM MAGNESIUM-2.0[**2146-7-1**] 11:55PM WBC-8.0 RBC-4.58* HGB-14.6 HCT-39.9* MCV-87MCH-31.9 MCHC-36.6* RDW-13.3[**2146-7-1**] 11:55PM PLT COUNT-161[**2146-7-1**] 11:55PM PT-13.2 PTT-27.9 INR(PT)-1.1[**2146-7-1**] 03:41PM TYPE-ART PO2-159* PCO2-49* PH-7.42 TOTALCO2-33* BASE XS-6[**2146-7-1**] 03:05PM CK(CPK)-165[**2146-7-1**] 03:05PM CK-MB-8 cTropnT-0.21*[**2146-7-1**] 03:05PM PLT COUNT-171Brief Hospital Course:Mr. [**Known lastname 2072**] was admitted to [**Hospital1 18**] from an OSH for
ACS
DISEASE
.1. CAD/ACS. OSH reported ECG with ST depressions inV2-V5/Elevation in III and negative CEAdmission Date: [**2123-8-15**] Discharge Date: [**2123-8-18**]Date of Birth: [**2078-9-26**] Sex: MService: MEDICINE
Allergies
DISEASE
:Penicillins / Bactrim / LamivudineAttending:[**First Name3 (LF) 3561**]Chief Complaint:Altered mental statusMajor Surgical or Invasive Procedure:central lineintubationparacentesisHistory of Present Illness:Hx per family and patientThis is a 44 year old gentleman with HIV on HAART (CD4 376 vl6000 in [**8-2**])hepatitis C
cirrhosis
DISEASE
who was brought in to ED byfamily after he was not returning phone calls for 6 days. Hisfather and brother found him lying in bed with soilage aroundhim--the house was in disarray. The patient appeared Admission Date: [**2116-7-3**] Discharge Date: [**2116-7-18**]Service: MEDICINE
Allergies
DISEASE
:TiclidAttending:[**First Name3 (LF) 30**]Chief Complaint:
Diarrhea
DISEASE
and
hypotension
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:This is a 86 y/o male with a h/o CAD
CHF
DISEASE
(EF 30-40%)
HTN MDS
DISEASE
recent admission in [**7-13**] for
diarrhea
DISEASE
and treatedpresumptively for c diff given his past history of c diff
enterocolitis
DISEASE
who now presents to the ED withn/v/weakness/dehydration/diarrhea/epigastric abd
pain
DISEASE
x 24hours. Pt also had one episode of
emesis
DISEASE
(no blood) yesterday.He is still on his course of flagyl from recent admission buthas missed the last few doses due to outpt pharmacy issues..In the [**Name (NI) **] pt was noted to have an elevated lipase and amylaseof 557 and 900 respectively. He was also noted to have anelevated lactate of 3.2 and a positive u/a with 6-10 wbc'strace leuks neg nitrates. He was initially to be admitted tomedicine however pt dropped his SBP from 110 to 90asymptomatic. Received 500 cc with good response and current SBPin the 100's. Received a total of 1 L NS. He was givenVanc/CTX/flagyl in the ED for h/o MRSA positive u/a and recenth/o c diff
enterocolitis
DISEASE
([**4-10**])..Currently through aid of daughter translating pt denies anyf/c/s dizziness/lightheadedness
chest pain
DISEASE
SOB
palpitations
DISEASE
n/v
abdominal pain
DISEASE
urinary symptoms. Admission Date: [**2132-10-6**] Discharge Date: [**2132-10-12**]Date of Birth: [**2058-10-28**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Known firstname 1283**]Chief Complaint:CP / CADMajor Surgical or Invasive Procedure:Iliac and aortic stent placement [**2132-10-6**]Re-do CABG X 4 AVR(tissue) [**2132-10-7**]History of Present Illness:This is a 73-year-old male who had a history of
coronary artery disease
DISEASE
and had underwent a left internalmammary artery H grafted with a radial artery to the leftanterior descending artery through a left anteriorthoracotomy many years ago. He had progressive
shortness of
breath
DISEASE
and was found to have critical
aortic stenosis
DISEASE
withaortic valve area of 0.8 cm squared and moderate mitralregurgitation. His ejection fraction was estimated to beabout a 25%. He also underwent a cardiac catheterizationwhich demonstrated that his H graft to the left anteriordescending artery was patent. He had a totally occluded leftanterior descending artery proximally. He also hadsignificant stenosis of his left circumflex artery and rightcoronary artery.It was recommended that he undergo a coronary artery bypassgrafting aortic valve replacement and possible mitral valverepair/replacement. After the risks and benefits wereexplained to the patient he agreed to proceed.Past Medical History:lisinopril 30' coreg 3.125Admission Date: [**2177-1-26**] Discharge Date: [**2177-2-2**]Date of Birth: [**2129-2-28**] Sex: FService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 3223**]Chief Complaint:s/p MVCMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:This is a 47 year old female who was in a motor scooter accidentin [**Country 3594**] 2 days ago. She reportedly had
loss of consciousness
DISEASE
and was admitted overnight in a hospital in [**Country 3594**]. Yesterdayshe presented to [**Hospital6 2561**] complaining of a
headache
DISEASE
and right elbow
pain
DISEASE
. A CT of the head there demonstrated rightskull
fractures
DISEASE
and a small left
intraparenchymal hemorrhage
DISEASE
.The patient was transferred here in stable condition. Other thanher
headache
DISEASE
she is complaining of slight
dizziness
DISEASE
but has no
focal neurologic complaints
DISEASE
.Past Medical History:
Depression
DISEASE
Social History:The patient is married. She occasionally drinks alcohol.Family History:Non-contributoryPhysical Exam:On admission:Afebrile stable vitalsGen: pleasant well-developed/well-nourished young femaleNeuro: GCS 15 alert oriented x 3 pupils 2--Admission Date: [**2168-12-13**] Discharge Date: [**2168-12-26**]Date of Birth: [**2141-2-21**] Sex: MService:HISTORY OF PRESENT ILLNESS: This is as 27-year-old male withhistory of
schizophrenia
DISEASE
and non compliance with medicationswho was transferred from [**Hospital **] Hospital as a
trauma
DISEASE
. Thepatient reportedly ran in front of a car on route 128. Thepatient was walking in the accessory [**Male First Name (un) **] of the highway wasstruck by a car that was taking the exit ramp. This occurredat a slow velocity. The patient was found face down with [**Initials (NamePattern4) **][**Last Name (NamePattern4) 2611**]
coma
DISEASE
scale of 3 and in the prehospital stage washemodynamically stable with strong pulses and intact gagreflex but dilated and fixed pupils. The patient wassubsequently transferred to [**Hospital **] Hospital and intubated.He was then transferred to [**Hospital1 188**] for definitive care. On arrival the patient was foundto have a superficial open
head laceration
DISEASE
a left open tibiaand fibula
fracture
DISEASE
and a laceration to the right upperextremity. The patient had received 1 gm of Ancef prior toarrival in the Emergency Room.PAST MEDICAL HISTORY: Schizophrenia. He has not beencompliant with medications and has been increasingly
paranoid
DISEASE
per the patient's father. There is question of a history of
rhythm disorder
DISEASE
.MEDICATIONS: Neurontin Risperdal.ALLERGIES: No known
drug allergies
DISEASE
.PAST SURGICAL HISTORY: Adenoidectomy tonsillectomy and leftupper extremity
fracture
DISEASE
.SOCIAL HISTORY: The patient lives at the [**Company 3596**] in [**Hospital1 **].Father lives in [**Hospital1 3597**]. The patient smokes and drinks alcoholbut denies recreational drug use.PHYSICAL EXAMINATION: The patient initially had a heart rateof 100 blood pressure 160/94 respiratory rate wasdetermined by respiratory therapist as he was intubated. Hewas satting 100%. The patient had a large equalizingposterior scalp avulsion and
forehead laceration
DISEASE
. These wereclosed immediately with staples. His left tympanic membranewas clear his right tympanic membrane had a question ofhemotympanum. His C spine was collared. There were nostep-offs. Chest is clear to auscultation bilaterally.Abdomen was soft nontender non distended. Pelvis isstable. There was decreased rectal tone and no gross blood.He had palpable dorsalis pedis pulses bilaterally and an open
fracture
DISEASE
at the left shin.LABORATORY DATA: White blood cell count 25.7 hematocrit43.3 platelet count 310000 fibrinogen 142. Urinespecific gravity 1.032 PH 5.0 [**7-10**] red blood cells rarebacteria. Sodium 137 potassium 4.5 chloride 101 CO2 28BUN 10 creatinine 1.0 glucose 137 amylase 63. Serumtoxicology screen was negative. Urine toxicology was alsonegative. Initial blood gas had PH 7.46 PCO2 40 PO2 287bicarb 29. A
trauma
DISEASE
series including AP view of the chestlateral C spine and AP view of the pelvis were read asnegative. CT of the C spine showed a linear non displaced
fracture
DISEASE
of the pars intraarticularis at C7. A CT of thehead showed a very small amount of subarachnoid blood seen onthe right tentorium. CT of the chest abdomen and pelvisshowed only a small area of consolidation in the left upperlobe and
bibasilar
DISEASE
dependent
atelectasis
DISEASE
. There was noevidence of other
injuries
DISEASE
. The left tib fib film showed amid shaft comminuted left tibial and fibular
fracture
DISEASE
. Aleft elbow x-ray was normal. T spine and LS spine x-rayswere also normal.HOSPITAL COURSE: The patient was brought to the operatingroom by orthopedic surgery for repair of the left tibia andfibular
fractures
DISEASE
and open reduction and internal fixationwas performed with placement of an intramedullary rod. Thepatient tolerated the procedure well and was subsequentlyadmitted to the Surgical Intensive Care Unit for closemonitoring. In the unit neurosurgery was consulted whocommented on the questionable area of subarachnoid
hemorrhage
DISEASE
. Their recommendation was to load with Dilantinwhich was promptly done. On hospital day #2 the patient wascompletely stable. Spine surgery was consulted for the C7 toT1 facet
fracture
DISEASE
who recommended that the patient continuethe C collar for approximately 6 weeks. The patient wasplaced on antibiotic prophylaxis with Ancef throughout hisIntensive Care stay. The patient was transferred to thefloor on [**2168-12-16**]. He was seen by psychiatry and followed upthroughout the next several days. He remained markedlyconfused with disorganized speech. This was initially feltto be consistent with the
schizophrenia
DISEASE
although afterseveral days of evaluation it was determined that this islikely a component of
traumatic
DISEASE
brain injury as well.Neurology was consulted and recommended MRI of the patient'shead. This study showed multiple areas of low signalinsusceptibility images at the [**Doctor Last Name 352**] white matter junctionindicative of diffuse
axonal injury
DISEASE
and bilateral frontal
subdural effusion
DISEASE
. There was also a large
hematoma
DISEASE
seenwhich was followed while the patient was on the hospitalfloor. It was determined that the patient would benefit froma neuro rehab facility. Case management screened the patientand placement is currently pending. The patient was kept ona 1:1 sitter throughout his entire hospital course. Physicaltherapy followed him for exercises. His range of motioninstructions at discharge are weight bearing as tolerated onthe left lower extremity. Dilantin was slowly weaned to offon [**2168-12-25**].DISCHARGE MEDICATIONS: Heparin 5000 units subcu [**Hospital1 **] whilethe patient is confined to bed. Risperdal 3 mg po bidPercocet [**2-2**] q 4 hours prn severe
pain
DISEASE
Tylenol 1 gm po q 4hours prn
pain
DISEASE
.DISCHARGE DIAGNOSIS:1. Status post struck by car.2. Head
trauma
DISEASE
with diffuse
axonal injury
DISEASE
.3. Schizophrenia.4. Left tibia and fibula
fracture
DISEASE
status post open reductionand internal fixation.5. C7 facet
fracture
DISEASE
. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**] MD [**MD Number(1) 3599**]Dictated By:[**Last Name (NamePattern1) 3600**]MEDQUIST36D: [**2168-12-26**] 11:50T: [**2168-12-26**] 13:14JOB#: [**Job Number 3601**]Admission Date: Discharge Date: [**2169-1-9**]Date of Birth: Sex: MService:ADDENDUM: The patient has been on a one to one sitter forquite some time. He however was placed in a Veil bed lastweek and the patient has been without a one to one sitter anddoing well for approximately four days now. Since thescreening process has been reinstituted and the patient isjust awaiting a rehab placement. DR.[**Last Name (STitle) 3598**][**First Name3 (LF) **] 02-352Dictated By:[**Name8 (MD) 3181**]MEDQUIST36D: [**2169-1-9**] 09:55T: [**2169-1-9**] 10:18JOB#: [**Job Number 3602**]Admission Date: [**2167-3-12**] Discharge Date: [**2167-3-15**]Date of Birth: [**2107-10-15**] Sex: MService: MEDICINE
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 425**]Chief Complaint:
chest pain
DISEASE
Major Surgical or Invasive Procedure:Cardiac catheterizationSwan-Ganz catheter placementEndotracheal intubationHistory of Present Illness:59 year old gentleman with a past medical history of CAD s/pCABG in [**2151**] with LIMA to LAD and RIMA to RCA
hyperlipidemia
DISEASE
htn and smoking. The patient was having symptoms of
shortness
DISEASE
of
breath and chest pain
DISEASE
unclear for how long and decided to goto his PCP who he had not seen in over two years. On route tothe office his symptoms worsened and he called his doctor whoadvised him to pull over and call 911. Taken by Ambulance to[**Hospital1 **] ER at 1130. There he received 325 aspirin 4 morphineand nitroglycerin drip. Arixtra (Fondiparinux) was also given.EKG revealed ST depressions in leads I aVL V3-V6. ST elevationin AVR. CK 99 MB and troponin unknown. The patient had worsened
dyspnea
DISEASE
and
hypoxia
DISEASE
had
pulmonary edema
DISEASE
on CXR and waselectively intubated (etomidate succinylcholine). Integrilinstarted and sent for catheterization. Left heart cath via rightfemoral artery reportedly with 95% lm occlusion native RCA andLAD are both occluded. LIMA and RIMA appeared patent..Pt received 40 IV lasix and transferred to [**Hospital1 18**] for furtherintervention. Became
hypotensive
DISEASE
to SBP 70-80 and was placed onneo gtt on route. On arrival to cath lab pt still pressordependent. Cath revealed critical Admission Date: [**2133-1-6**] Discharge Date: [**2133-1-8**]Date of Birth: [**2090-3-15**] Sex: MService: MEDICINE
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 1646**]Chief Complaint:PCP: [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 3604**].CHIEF COMPLAINT: visual changesREASON FOR MICU ADMISSION: PCN desensitization.Major Surgical or Invasive Procedure:PCN desensitizationHistory of Present Illness:Pt is a 42 y.o male with h.o HIV (last CD4 479 VL 13700) noton HAART who was started on doxycycline (PCN allergy) 5 days agofor secondary syphilis (titer 1:64). He reported to his PCP thathe had been having
visual problems
DISEASE
for the past month. He wassent urgently to ophthal where b/l anterior
uveitis
DISEASE
and b/l disc
edema
DISEASE
was seen. He was sent to the ED for imaging LP withthoughts of PCN desensitization. Pt was referred for
infectious
DISEASE
w/u..Pt states that since [**Month (only) **] he developed
chills skin rash
DISEASE
(purple/pink spots on torso/arms/face/neck/penis
joint pains
DISEASE
swollen cervical lymph nodes abdominal bloating (
constipation
DISEASE
)as well as visual changes (white lights in periphery whitecircles and lines). Pt denies
fever
DISEASE
eye
pain photophobia
DISEASE
neckstiffness CP/SOB/palp abdpain/n/v/d/c/melena/brbpr/dysuria/hematuria/parestheisas or
weight loss
DISEASE
.Admission Date: [**2130-6-1**] Discharge Date: [**2130-6-7**]Date of Birth: [**2061-8-26**] Sex: MService: SURGERY
Allergies
DISEASE
:Codeine / Meperidine / Iodine Containing Agents ClassifierAttending:[**First Name3 (LF) 695**]Chief Complaint:
Autoimmune hepatitis
DISEASE
HCC
DISEASE
Major Surgical or Invasive Procedure:Left hepatic lobectomy caudate lobe resection cholecystectomyintraoperative ultrasound.History of Present Illness:The patient is a 68-year-old male with a history of
auto-immune
DISEASE
hepatitis
DISEASE
and
cirrhosis
DISEASE
who developed right upper quadrant
abdominal pain
DISEASE
. An ultrasound demonstrated a large mass in theright lobe of the liver that on biopsy was consistent with
hepatocellular carcinoma
DISEASE
. His AFP was 336. A CT scan of thechest and abdomen demonstrated no evidence of pulmonarymetastases. The patient had a large mass lesion measuring 12.7 x9.2 x 11.2 cm arising primarily in the medial segment of theleft lobe. The middle hepatic vein was not visualized but theright hepatic vein and the left lateral segment hepatic veinswere identified. The mass lesion superiorly appears to abut notinvade the right lobe of the liver. The patient does not haveevidence of portal
hypertension
DISEASE
. The patient after informedconsent is now brought to the operating room for left hepaticlobectomy possible left trisegmentectomy caudate loberesection and cholecystectomy.Past Medical History:hyperchol
HTN
DISEASE
CAD s/p CABG (echo --Admission Date: [**2157-12-15**] Discharge Date: [**2157-12-23**]Date of Birth: [**2099-4-13**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Ciprofloxacin / Levaquin / Opioid AnalgesicsAttending:[**First Name3 (LF) 1505**]Chief Complaint:
Dyspnea
DISEASE
on exertionMajor Surgical or Invasive Procedure:[**2157-12-15**] Aortic Valve Replacement (21mm CE tissue valve)History of Present Illness:58 y/o female with known AS. Followeed by serial echo's andcardiac cath which have shown progression of
aortic stenosis
DISEASE
.Admits to increased chest discomfort DOE and
fatigue
DISEASE
over thelast several years.Past Medical History:
Aortic Stenosis Hypertension Hypercholesterolemia
DISEASE
Peripheral[**Month/Day/Year **] Disease
Carotid Disease
DISEASE
End-Stage
Renal Disease
DISEASE
(prev. on
HD
DISEASE
)
Diabetes Mellitus
DISEASE
Admission Date: [**2159-4-6**] Discharge Date: [**2159-4-10**]Date of Birth: [**2120-1-29**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**Doctor First Name 2080**]Chief Complaint:Blurry visionMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:This is a 39 year old male with a history of
hypertension
DISEASE
(onbeta blockade lasix hydralazine imdur metolazone)complicated by
chronic kidney disease
DISEASE
(stage IV) EF of 25-30%
obesity
DISEASE
and
tobacco abuse
DISEASE
. He presented today to the emergency room after[**Hospital 2081**] clinic noted severe bilateral papilledemaAdmission Date: [**2158-6-13**] Discharge Date: [**2158-6-21**]Date of Birth: [**2099-4-13**] Sex: MService: MEDICINE
Allergies
DISEASE
:Ciprofloxacin / Levaquin / Opioid AnalgesicsAttending:[**First Name3 (LF) 826**]Chief Complaint:Recurrent high
fevers HTN
DISEASE
increased O2 reqMajor Surgical or Invasive Procedure:Central venous catheter insertionHistory of Present Illness:59 yo M w/ PMH
ESRD
DISEASE
s/p renal tx in [**2155**] on immunosuppressants
HTN DM
DISEASE
who presented to OSH with fevers/fatigue and tx to [**Hospital1 18**]for concern of
sepsis
DISEASE
. He experienced
fatigue
DISEASE
after workingoutside in hot weather and later that day was noted to have a
fever
DISEASE
to 104. He went to [**Hospital **] Hosp where he was
febrile
DISEASE
to104. He was given levofloxacin and IVFs and transferred to [**Hospital1 18**]where he was admitted to the ICU for
sepsis
DISEASE
..He denies current f/c/sweats. He denies cp/sob/cough. He denies
n/v/abd pain
DISEASE
. He denies
dysuria
DISEASE
. He denies URI sx/sorethroat/myalgias. He denies LAD/swelling/rash..Past Medical History:1.
Congestive heart failure
DISEASE
with EF 65% on [**2158-6-13**]2. Type 2 diabetes with
triopathy
DISEASE
controlled.3.
Hypertension
DISEASE
.4.
Hypercholesterolemia
DISEASE
.5. History of
seizure disorder
DISEASE
.6. History of
hepatitis C
DISEASE
- no therapy - [**11-21**] bx -Minimalportal and lobular mononuclear cell
inflammation
DISEASE
consistentwith involvement by chronic
viral hepatitis
DISEASE
C ( Grade 1activity).7.
End-stage renal disease
DISEASE
status post cadaveric renaltransplant creatinine 1.2-1.5in [**2155-2-16**].8. Peripheral [**Year (4 digits) 1106**] disease.9. Post-Op AFIB s/p DCCV in [**2-22**]10. Rt rectus femoris intramuscular
hematoma
DISEASE
- [**2-22**] (INR 4.2)11. Admission Date: [**2159-5-26**] Discharge Date: [**2159-6-12**]Date of Birth: [**2099-4-13**] Sex: MService: MEDICINE
Allergies
DISEASE
:Ciprofloxacin / Opioid Analgesics / LevaquinAttending:[**First Name3 (LF) 759**]Chief Complaint:
fever
DISEASE
Major Surgical or Invasive Procedure:Intubation/ExtubationRIJ central line now removedLumbar punctureHistory of Present Illness:60 y.o. M with hx of
ESRD
DISEASE
s/p cadaveric renal tx in [**2155**] onimmunosuppressants Hep C
HTN
DISEASE
[**Year (4 digits) 2320**]
PVD
DISEASE
presents from homewith fever to 105.8. Patient says he was in his usual state ofhealth as recently as Weds when he saw his cardiologist inpreparation for
hernia
DISEASE
repair surgery early next week. Some ofhis usual medications including his prophylactic bactrim wereheld and he stayed home from work trying to avoid sick contactspre-operatively. On Thursday afternoon he started to feel somemalaise and his temperature started to rise. He took sometylenol and his
fever
DISEASE
appeared initially to abate but returned[**Year (4 digits) 2974**] with
nausea
DISEASE
and
vomiting
DISEASE
constant
shivering
DISEASE
shoulder
aches headaches
DISEASE
and three episodes of loose stools. Deniesany urinary symptoms (no changes in
color consistency dysuria
DISEASE
frequency urgency) abd
pain
DISEASE
neck stiffness cough or coldsymptoms. No sick contacts. [**Name (NI) **] recent travel. He was lastadmitted to [**Hospital1 18**] from [**4-23**] to [**5-2**] for new diagnosis of
atrial
flutter acute on chronic renal failure
DISEASE
and
HAP
DISEASE
..In the ED patient had labs which showed and elevated whitecount with a 10%
bandemia
DISEASE
. He had a CXR which was negative forany acute process. A R IJ line was placed and he was started onVancomycin and Gentamycin for presumptive
endocarditis
DISEASE
. UAurine culture and blood cultures were sent. No recent invasivedental work. No recent IVDU.Past Medical History:
Congestive heart failure
DISEASE
with EF 65% on [**2158-6-13**]Type 2 diabetes with
triopathy
DISEASE
controlled.
Hypertension
DISEASE
.
Hypercholesterolemia
DISEASE
.History of
seizure disorder
DISEASE
.History of
hepatitis C
DISEASE
- no therapy - [**11-22**] bx -Minimal portaland lobular mononuclear cell
inflammation
DISEASE
consistent withinvolvement by chronic
viral hepatitis
DISEASE
C ( Grade 1 activity).
End-stage renal disease
DISEASE
status post cadaveric renaltransplant creatinine 1.5 in [**2159-4-17**]Peripheral [**Year (4 digits) 1106**] disease.Post-Op AFIB s/p DCCV in [**2-22**]Rt rectus femoris intramuscular
hematoma
DISEASE
- [**2-22**] (INR 4.2)Admission Date: [**2167-7-31**] Discharge Date: [**2167-8-7**]Date of Birth: [**2105-6-24**] Sex: MService:HISTORY OF PRESENT ILLNESS: The patient is a 62 -year-oldmale with known history of
coronary artery disease
DISEASE
statuspost
myocardial infarction
DISEASE
with angioplasty in [**2155**]. He hasa history of increased cholesterol family history of heartdisease and states he has had
angina
DISEASE
symptoms for manyyears. He said within the last year his symptoms haveincreased with
concomitant shortness of breath
DISEASE
. The patientstated that he was golfing roughly four days prior toadmission and had episodes of left sided
chest pains
DISEASE
whichradiated to the shoulder and arm.The patient on [**2167-7-29**] presented to an Emergency Room forrule out
myocardial infarction
DISEASE
and the
myocardial infarction
DISEASE
was ruled out with enzymes and electrocardiogram. On[**2167-7-30**] the patient started exercising had increased chest
pains
DISEASE
for roughly seven minutes which resolved. The patientwas then worked up for a
myocardial infarction
DISEASE
once again andwas transferred to a Catheterization Lab for possibleangioplasty.PAST MEDICAL HISTORY:1. Coronary
artery disease
DISEASE
status post myocardial
infarction
DISEASE
in [**2155**].2. Status post angioplasty of the left circumflex in [**2155**].3.
Gastroesophageal reflux disease
DISEASE
.4. Hypertension.5. Hypercholesterolemia.6. Benign
prostatic hypertrophy
DISEASE
.7. Dupuytren contractures.ADMITTING MEDICATIONS: Include Lipitor 40 mg Cardizem 120mg q day aspirin 325 mg q day Flomax 0.4 mg q day Ambien5.0 mg HS and Ativan 0.5 mg tid prn.ALLERGIES: Include contrast dye.PHYSICAL EXAMINATION: On initial examination vital signs:blood pressure 150/90 heart rate 50. Neck: negative jugular
venous distention
DISEASE
. Chest is clear to auscultation. Heart:regular rate and rhythm. Abdomen: soft nontender positivebowel sounds. Extremities: Admission Date: [**2115-7-2**] Discharge Date: [**2115-7-15**]Date of Birth: [**2052-5-19**] Sex: FService: ORTHOPAEDICS
Allergies
DISEASE
:PercocetAttending:[**First Name3 (LF) 3645**]Chief Complaint:
back pain buttock pain
DISEASE
and exacerbated
leg pain
DISEASE
Major Surgical or Invasive Procedure:1. Bilateral L3 laminotomies medial facetectomies andforaminotomies of the L4 nerve root.2. Bilateral laminectomy of L5 with medial facetectomy of L4-L5and foraminotomies bilaterally at the L5 nerve roots.3. Complex repair and allograft placement of a dural tear.4. Placement of lumbar drain L1-2.History of Present Illness:Mrs. [**Known lastname 1391**] was having anterior quads symptoms and legsymptoms that were on top of her acute chronic back pain. Sheis currently on MS Contin and Neurontin. She is [**8-28**] at rest[**9-27**] with activity. However she is almost 90%
back pain
DISEASE
andthis is what stops her and not leg
pain
DISEASE
. She has hadsignificant benefit from mild ablation in her back previously.Her
thigh pain
DISEASE
has certainly settled down on the Neurontin.Past Medical History:Asthma
COPD
DISEASE
hypothryroidism
DISEASE
Depression
DISEASE
hyperlipidemia
DISEASE
Social History:Currently married smokes cigarettesFamily History:Colon CAPhysical Exam:On Discharge:AAdmission Date: [**2161-2-14**] Discharge Date: [**2161-3-10**]Date of Birth: [**2098-9-3**] Sex: MService:HISTORY OF PRESENT ILLNESS: This 61 year-old male with a tenyear history of progressive
Parkinson's disease
DISEASE
tripped overhis own feet and fell down approximately seven steps. Hestates for a few seconds he was stunned and felt tingling inall four extremities. He also noted
pain
DISEASE
in his legs leftgreater then right and in his right chest. He was taken to[**Hospital **] Hospital where he was reportedly neurologicallyintact. He was in a cervical collar. A CT scan of thecervical spine was obtained. This showed a
fracture
DISEASE
of theanterior arch of C1. There was a moderately displaced
comminuted odontoid fracture
DISEASE
extending through the basewhich moderately narrowed the spinal canal. The dens and C1were displaced approximately 13 mm. The patient was able tovoid spontaneously times two before a Foley catheter wasplaced. The patient has been followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] inNeurology for his
movement disorder
DISEASE
.PAST MEDICAL HISTORY: The patient has a history of
bipolar
DISEASE
disorder and
Parkinson's syndrome
DISEASE
.ALLERGIES: He is
allergic
DISEASE
to Haldol.MEDICATIONS:1. Sinemet.2. Folate.3. Valproic acid.4. Seroquel.5. Amantadine.LABORATORIES ON ADMISSION: White blood cell count of 9.3hematocrit 41.4 platelet count 157 amylase 42 sodium 143potassium 5.0 chloride 106 CO2 28 BUN 22 creatinine 1.1glucose 122 lactacid 1.6.PHYSICAL EXAMINATION: The patient is alert and orientedtimes three. He is complaining of a
headache
DISEASE
posterior neck
pain
DISEASE
and right
chest pain
DISEASE
. He has a marked resting
tremor
DISEASE
primarily effecting his left upper extremity and left lowerextremity. There is cogwheel
rigidity
DISEASE
of both upperextremities. His cranial nerves are intact. He describesaltered sensation and
pain
DISEASE
to light touch and pin prick overhis left occiput and right chest at approximately the T2 toT5 levels. There is no clear sensory level to pin pricklight touch position direction or vibration. The patient's
cervical collar fits
DISEASE
well. His toes are upgoing. Hisreflexes are 2Admission Date: [**2171-6-4**] Discharge Date: [**2171-6-21**]Date of Birth: [**2092-5-17**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:Fosamax / Actonel / Iodine / Solu-Cortef / Advair DiskusAttending:[**First Name3 (LF) 1505**]Chief Complaint:increasing DOEMajor Surgical or Invasive Procedure:CABGx1(SVG-Service: Date: [**2129-10-12**]Date of Birth: [**2077-7-1**] Sex: FSurgeon: [**Name6 (MD) 3661**] [**Name8 (MD) 3662**] M.D.PREOPERATIVE DIAGNOSIS:POSTOPERATIVE DIAGNOSIS:CHIEF COMPLAINT: Tetany
muscle spasms
DISEASE
.HISTORY OF THE PRESENT ILLNESS: The patient is a 52-year-oldfemale who awoke on the morning of admission with bodytingling. She felt
numb
DISEASE
and felt as though she had troublemoving her arms and legs. At 8 o'clock on the morning ofadmission the patient called the EMS. She was otherwise inher usual state of health. She has noticed over the pastseveral day
constipation
DISEASE
which was treated with PO Dulcolaxwith several watery stools the day before admission.PAST MEDICAL HISTORY:1. History of
seizure disorder
DISEASE
.2. Hypotension.3. Fibromyalgia.4. Hypoxic brain injury secondary to
overdose
DISEASE
.5. Depression with several suicide attempts.MEDICATIONS ON ADMISSION:1. Prozac 40 mg PO b.i.d.2. Klonopin 2 mg PO q.i.d.3. Flexeril 10 mg PO t.i.d.4. Ibuprofen 600 mg PO q.i.d.5. [**Doctor First Name **] 60 mg PO b.i.d.6. Risperdal 2 mg PO b.i.d.7. Colace 100 mg PO b.i.d.8. Albuterol/Atrovent MDIs p.r.n.ALLERGIES: The patient is allergic to PENICILLIN ANDCODEINE.REVIEW OF SYSTEMS: The patient has no
headache
DISEASE
no visualchanges no nausea no vomiting no
fever
DISEASE
no
chills
DISEASE
noseisure no changes in diet no
abdominal pain
DISEASE
no shortnessof
breath no chest pain
DISEASE
no changes in medications recently.SOCIAL HISTORY: The patient has positive tobacco use. Noalcohol use.PAST MEDICAL HISTORY: The patient has history of multiplerecreational drug use.PHYSICAL EXAMINATION: Examination on admission revealed thefollowing: Temperature 96.9 blood pressure 108/48 heartrate 80s respiratory rate 20. Oxygen saturation 98% on twoliters. GENERAL: The patient was alert oriented timesthree. Oropharynx was dry. Neck was supple withjugulovenous distention. CARDIOVASCULAR: Regular rate andrhythm normal S1 and S2. LUNGS: Bibasilar crackles.ABDOMEN: Soft nontender nondistended normoactive bowelsounds. No
hepatosplenomegaly
DISEASE
. EXTREMITIES: Warm with goodpulses no edema. NEUROLOGICAL: Extraocular muscles areintact. Pupils equal round reactive to light andaccommodation. MOUTH: Clenched closed tongue midline.SENSORY: Sensory examination was normal. Strength 5/5 inall muscle groups. Reflexes: 0 through 1 throughout.LABORATORY DATA: Labs on admission revealed the following:White blood count 8.0 hematocrit 32.8 platelet count287000 INR 1.2 PTT 23.5 sodium 137 potassium 2.4chloride 92 bicarbonate 29 BUN 13 creatinine 0.9 glucose74 magnesium 1.0 free calcium 0.78 CK 128 troponin lessthan 0.3. ABG: The pH was 7.51 CO2 40 pO2 45 toxicologyscreen negative. Chest x-ray revealed mild congestive heartfailure. Echocardiogram: Mild MR normal left ventricularejection fraction greater than 55%. EKG: Normal sinusrhythm PR of 0.174. QTC: 476 milliseconds slightlyprolonged compared to previous.HOSPITAL COURSE: In the ED the patient received one ampuleof calcium 2 grams of magnesium 6 liters of fluid. Thepatient was treated with Levofloxacin Flagyl andHydrocortisone.The patient was admitted to the Medical Intensive Care Unitfor management of electrolytes. The patient was givenseveral ampules of calcium gluconate with improvement of thefree calcium as well as the total calcium. On [**10-11**] in the morning the patient admitted to using Dulcolaxon a daily basis and also frequent use of Fleet Phospho-Sodaenemas and wanted to make sure that the staff knew that thiscould be the possible etiology of her current symptoms.The patient was continued to be hydrated with IV fluids.Electrolytes were repleted. Calcium continued to improve.The patient was transferred to the floor for management.Calcium was then repleted with one gram PO calcium carbonatewith improvement of free calcium to a normal range. Allother electrolytes were repleted as well.The Department of Psychiatry was consulted for evaluation ofthe patient laxative abuse. It was felt that the use wassecondary to constipation and not likely due to bodydysmorphic disorder or attempts to lose weight. Howeverrecommend follow up as an outpatient which the patient willdo through her outpatient therapist as well as her primarycare physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. The patient agrees to usenonstimulant bowel regimen which included Milk of MagnesiaColace and Senna. The patient will follow up with theprimary care physician for better bowel regimen managementand possible gastrointestinal follow up. At the time ofdischarge the patient's symptoms of
tetany
DISEASE
and
muscle spasms
DISEASE
had completely resolved and the electrolytes were normalized.DISCHARGE DIAGNOSES:1. Hypocalcemia.2. Laxative abuse.CONDITION ON DISCHARGE: Good.MEDICATIONS ON DISCHARGE:1. Prozac 40 mg PO b.i.d.2. Klonopin 2 mg PO q.i.d.3. Flexeril 10 mg PO t.i.d.4. Ibuprofen 600 mg PO q.i.d.5. [**Doctor First Name **] 60 mg PO b.i.d.6. Risperdal 2 mg PO b.i.d.7. Colace 100 mg PO b.i.d.8. Albuterol/Atrovent MDI p.r.n.9. Senna one tablet PO q.h.s.10. Milk of Magnesia PO p.r.n.
constipation
DISEASE
.11. Calcium carbonate one gram PO b.i.d.FOLLOW-UP CARE: The patient is to follow up with her primarycare physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] who was Emailed. The patient willsee Dr. [**Last Name (STitle) **] later this week or possibly the week after. [**Name6 (MD) 251**] [**Name8 (MD) **] M.D.Dictated By:[**Doctor Last Name 3663**]MEDQUIST36D: [**2129-10-12**] 16:07T: [**2129-10-13**] 15:05JOB#: [**Job Number 3664**]Admission Date: [**2131-12-18**] Discharge Date: [**2132-1-1**]Date of Birth: [**2077-7-1**] Sex: FService: MEDICINE
Allergies
DISEASE
:Penicillins / Meperidine & Related / Codeine / PropoxypheneAttending:[**First Name3 (LF) 898**]Chief Complaint:admit to [**Hospital Unit Name 153**] for RML pneumonia hypotensionMajor Surgical or Invasive Procedure:Intubation [**12-21**]History of Present Illness:54yo woman presented to the ED with 2 days of
fevers cough
DISEASE
and
muscle aches
DISEASE
. Also had right sided sharp stabbing [**10-28**]pleuritic
chest pain
DISEASE
and
shortness of breath
DISEASE
exacerbated by
cough
DISEASE
or inspiration. No
anginal symptoms
DISEASE
. In ED receivedceftriaxone azithromycin as well as aspirin. Initial SBP inthe 80's and received 3L NS and started on levophed gttAdmission Date: [**2134-2-28**] Discharge Date: [**2134-3-19**]Date of Birth: [**2077-7-1**] Sex: FService: MEDICINE
Allergies
DISEASE
:Penicillins / Meperidine & Related / Codeine / PropoxypheneAttending:[**First Name3 (LF) 783**]Chief Complaint:
hypotension acidemia hyponatremia tachypnea
DISEASE
Major Surgical or Invasive Procedure:intubation central line placement.History of Present Illness:56-year-old female with a history of
chronic abdominal pain
DISEASE
laxative abuse
DISEASE
and
chronic diarrhea
DISEASE
who complained of shornessof breath. Had been admitted for worsening abdominalpain/distension
chills
DISEASE
and
diarrhea
DISEASE
. CT demonstrate illeus vs.low grade SBO. Had been stable on floor..Upon evaluation of patient by floor team she had a RR in the30's but oxygenating well on 4L NC. Patient complained ofworsening
abdominal pain shortness of breath
DISEASE
. BP 82/42 butdecreased to the 70's (baseline BP's in the 80's to 90's). P110 afebrile. ABG 7.25/27/105/12 on 4L NC (baseline pCO250's-60's)..Patient with only 22g PIV x 1. Saline started and brought tounit. Line placed with difficulty. Sterilly prepped for R SCor R IJ. Unable to locate R subclav after mult sticks (4) andaccessed R SC artery. Then converted to R IJ and accessed withUS. Line placement sterile but may be compromised. Patientcomplaining of
abdominal pain
DISEASE
. NGT placed to suction withfeculent material..ABX course in ICU:[**3-1**]: vanc flagyl cipro for broad coverage[**3-2**]:
UTI
DISEASE
w/
E.coli
DISEASE
cipro d/c'd started on ceftriaxone (10 daycourse).[**3-4**]: vanco stopped[**3-6**]: Started azithromycin for atypical coverage[**3-7**]: current abx include azithro vanco and zosyn. the flagyland ctx were stopped..Vancomycin: [**Date range (1) 3698**]Flagyl: [**3-1**] - [**3-7**]Ceftriaxone [**3-2**] - [**3-7**]Azithromycin: [**3-6**] - [**3-9**]Zosyn: [**3-7**] - [**3-10**]Past Medical History:1. History of
laxative abuse
DISEASE
2.
Anorexia nervosa
DISEASE
3.
Bipolar disorder
DISEASE
4.
Borderline personality disorder
DISEASE
5.
Seizure
DISEASE
disorder- Pt's last
seizure
DISEASE
was in [**2126**] - reportedlyin the setting of alcohol withdrawal.6.
PTSD
DISEASE
7. H/O multiple suicide attempts - cut wrists and multiple drugODs8.
CHF
DISEASE
is listed as a diagnosis but her ECHO is normal and shehas not clinically been in
heart failure
DISEASE
recently per history.9.
Breast cancer
DISEASE
s/p resection- Pt was not treated with chemo orradiation therapy.10. H/O Bell's
palsy
DISEASE
11. [**Name (NI) 3672**] Pt is on 2L oxygen at home. (reduced DLCO butrestrictive physiology on PFTs)12. Fibromyalgia13.
Arthritis
DISEASE
14. Admission Date: [**2136-2-28**] Discharge Date: [**2136-3-7**]Date of Birth: [**2077-7-1**] Sex: FService: MEDICINE
Allergies
DISEASE
:Penicillins / Meperidine & Related / Codeine / PropoxypheneAttending:[**First Name3 (LF) 800**]Chief Complaint:
Dyspnea
DISEASE
and pleuritic
chest pain
DISEASE
Major Surgical or Invasive Procedure:Transfusion of 1unit of pRBCsHistory of Present Illness:History of Present Illness: Ms. [**Known lastname **] is 58 year old female withhistory of
COPD
DISEASE
Systolic
CHF
DISEASE
(EF 45-50%)
Bipolar disease
DISEASE
Borderline Personality Disorder
DISEASE
severe
pain depression
DISEASE
RAand oxygen use (4L without a clear-cut rationale). She wasadmitted today for
chest pain
DISEASE
and
dyspnea
DISEASE
..Ms. [**Known lastname **] reports that she had the flu last week and beganexperiencing diffuse
chest pain
DISEASE
(10Admission Date: [**2101-10-25**] Discharge Date: [**2101-10-28**]Date of Birth: [**2064-10-2**] Sex: FService: MEDICINE
Allergies
DISEASE
:Cephalosporins / Floxin / PenicillinsAttending:[**First Name3 (LF) 2108**]Chief Complaint:Xanax Tylenol & Klonopin
Overdose
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:37 yo F with history of
depression
DISEASE
and suicidal attempt in thepast presented with
obtundation
DISEASE
. Of note her prior attempt wasabout 15 years ago during which she OD on theophyllinerequiring intubation. She has been feeling more
depressed
DISEASE
overthe last few months and has been seeing a therapist on the ECTwaiting list with recent evaluation by Dr. [**Last Name (STitle) 2109**] [**First Name3 (LF) **] herpartner. [**Name (NI) **] reports taking 120 mg of Xanax and 80 mgKlonopin in the afternoon of [**2101-10-25**] as well as at least [**4-7**]g of Tylenol daily over the last 2 weeks. She also admitted totaking 20 mg of Ambien. She says that she was taking thetylenol intentionally to worsen her liver function. She saysthat she decided to do this because she wanted to commitsuicide. She also reports having had 1 glass of wine on the dayof these medication ingestions. She then called one of herfriends afterwards and her therapist ([**First Name8 (NamePattern2) 2110**] [**Last Name (NamePattern1) **]) wassubsequently involved and called the EMS for patient.In the ED her initial VS were HR 99 BP 102/56 RR 20 and 98%on
RA
DISEASE
. She arrived with her friend very lethargic. Perreport was only responsive to sternal rub and
GCS
DISEASE
of 8throughout. Tox screen showed positive benzos and acetaminophenonly. ECG showed
sinus tachycardia
DISEASE
. UA was negative. CT headdid not show
ICH
DISEASE
. Her initial Tylenol level was 40. Toxicologywas consulted and recommended NAC for 21 hours until level isundetectable and LFT stabilizes. She started NAC in the ED andher repeat level was 29. VS prior to transfer were T95 HR 66BP 121/73 RR 22 O2Sat 98%
RA
DISEASE
.She was transferred to the ICU for her poor mental status.While on the floor appears comfortable denies any SOB chestpain/discomfort abdominal pain/discomfort urinary symptoms orURI symptoms. She does have some
throat tightness
DISEASE
anddiscomfort when swallowing. Her partner reports that patient'smental status seems to have improved since her initial arrivalto the ED.Past Medical History:- Asthma requiring 1x intubation in late teen (unclear if thiswas related to the theophylline)- GERD with severe
esophagitis
DISEASE
([**2098**])- Insomnia- Bipolar Type 2 currently severe
depression
DISEASE
requiringhospitalization at [**Doctor First Name **] in the past-
Depression
DISEASE
- Suicidal attempts (last [**1-/2099**] following impulsive suicideattempt in which she crashed her cars 2 other ones with OD inher late teens)Social History:Occupation: a nurse mid-wife at [**Name (NI) 2025**] x 10 yearsDrugs: Marijuana last used about 1 week agoTobacco: NoneAlcohol: occasionallyMarried to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 976**] [**Telephone/Fax (1) 2111**] live in [**Location (un) 538**].Family History:- mother-
depression
DISEASE
- maternal grandmother- EtOH abuse benzodiazepine abuse- maternal uncle-
bipolar affective
DISEASE
d/oPhysical Exam:Physical Exam on Arrival to [**Hospital Unit Name 2112**]: Temp: 36.9 BP 116/51 HR 65 RR25 O2Sat 99%
RA
DISEASE
General: lethargic answers questions appropriately but inwhispers follows commands NADHEENT: PERRL EOMi anicteric Mucous membrane moistNECK: no supraclavicular or cervical LAD no JVD no carotid
bruits
DISEASE
no
stridor
DISEASE
Resp: CTAB with good air movement throughout no wheezecrackles or rhonchiCV: RR S1 and S2 wnl no m/r/gABD: soft ND mildly tender in the umbilical area no
hepatosplenomegaly
DISEASE
no guarding.EXT: no c/c/eSKIN: no rashes/no
jaundice
DISEASE
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits
DISEASE
to light touch appreciated.Pertinent Results:[**2101-10-25**]- CT head: There is no acute
intracranial hemorrhage
DISEASE
acutelarge majorvascular territory infarction discrete masses mass effectbrain
edema
DISEASE
orshift of normally midline structures. The ventricles and sulciare normal in size and configuration. The visualized osseousstructures are unremarkable. The visualized paranasal sinusesare within normal limits. Incidentally noted is afaintly-calcified likely sebaceous cyst in the leftparamedian frontovertex scalp soft tissues (2:26-27)Admission Date: [**2137-7-28**] Discharge Date: [**2137-7-31**]Date of Birth: [**2077-7-1**] Sex: FService: MEDICINE
Allergies
DISEASE
:Sulfa (Sulfonamide Antibiotics) / Latex / Demerol / Codeine /Penicillins / PropoxypheneAttending:[**First Name3 (LF) 2108**]Chief Complaint:
Overdose
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:Ms. [**Known lastname **] is a 60-year-old female with past medical historysignificant for
Bipolar disorder
DISEASE
borderline personalitydisorder multiple suicide attempts h/o
alcoholism PTSD COPD
DISEASE
on home O2 breast cancer s/p lumpectomy who presented to ED viaEMS after being found disoriented and wandering around herhousing complex barefoot with 1 empty and 1 full bottle ofclonazepam. She had 1 empty bottle of clonazepam filled [**7-14**]with 0 tablets and a 2nd bottle of clonazepam filled with 39pills (filled yesterday so 21 tablets gone). She is supposed tobe taking up to 4 pills per day per [**Month/Year (2) **]. Patient states onfurther history that she dropped Admission Date: [**2176-11-17**] Discharge Date: [**2176-11-24**]Date of Birth: [**2096-10-24**] Sex: MService: SURGERY
Allergies
DISEASE
:E-MycinAttending:[**First Name3 (LF) 371**]Chief Complaint:right sided
abdominal pain
DISEASE
Major Surgical or Invasive Procedure:laparoscopic cholecystectomyHistory of Present Illness:80 year old male who is well-known to thesurgical service who presented on [**11-13**] with
abdominal pain
DISEASE
andwas found to have evidence of
choledocholithiasis
DISEASE
. He underwentERCP on [**11-14**] for delivery of stone and sphincterotomy withstentplacement. He was discharged yesterday and was
pain
DISEASE
free until9pm this evening. He describes sudden onset of right sided
abdominal burning
DISEASE
that is identical in character to the
pain
DISEASE
thatoriginally brought him to the hospital several days prior. Hecurrently denies nausea/vomiting/fevers/chills.Past Medical History:
Degenerative arthritis
DISEASE
right knee
gout
DISEASE
prostate Ca s/p XRT and Lupronsecondary
gynecomastia
DISEASE
(resolved)CAD s/p PTCA/2 stents
glaucoma
DISEASE
mild
hearing impairment
DISEASE
non-toxic
goiter
DISEASE
hypertension
DISEASE
hypercholesterolemia
DISEASE
hiatal hernia
DISEASE
with
GERD
DISEASE
mild
irritable bowel syndrome
DISEASE
history of
intestinal polyps
DISEASE
(benign)hemorrhoidsPast Surgical History:
glaucoma
DISEASE
surgeryb/l
cataract
DISEASE
surgeryInginal
hernia
DISEASE
'[**70**] (Dr. [**Last Name (STitle) **]meniscus knee surgerySocial History:lives with wife runs a businessprior tobacco Admission Date: [**2187-10-29**] Discharge Date:Date of Birth: [**2135-10-28**] Sex: FService: [**Last Name (un) **]HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 3761**] is a 52-year-oldfemale who was transferred to the [**Hospital1 190**] in hyperacute
fulminant liver failure
DISEASE
thoughtto be secondary to either Bactrim reaction versusacetaminophen toxicity. She was admitted to the medicalintensive care unit initially and became progressivelyobtunded with significant
encephalopathy
DISEASE
requiringintubation and ventilatory support. Her liver function wasnotable for transaminases with an ALT and AST of 9500 and17500 respectively and worsening
hyperbilirubinemia
DISEASE
. Shebecame progressively more
coagulopathic
DISEASE
and it was thoughtthat she was most likely going to need orthotopic livertransplantation for survival. Given the critical nature ofher illness she was transferred to the transplant surgicalservice and to the surgical intensive care unit for furthermanagement. This management initially entailed aggressivecontrol and monitoring of intracranial pressures inconjunction with the neurosurgical service. This requiredplacement of an
intracranial bolt
DISEASE
and aggressive volumemanagement with the use of hypertonic saline and mannitol.She continued to receive aggressive cardiopulmonary supportwith again as noted full ventilatory support andvasopressor support for
hypotension
DISEASE
.COURSE BY SYSTEMS: Neurologically as noted above thepatient required placement of an
intracranial bolt
DISEASE
for ICPmonitoring. Her ICPs had climbed into the high 30s. This wasmanaged with
hyperventilation
DISEASE
and usage of mannitol andhypertonic saline. Over the course of the next 4-5 days asher liver function improved her intracranial pressuresdecreased. Her sedation and paralytics were weaned. She hadremoval of her
intracranial bolt
DISEASE
on [**2187-11-6**] and itwas noted on subsequent imaging that she had approximately a4-cm right frontal
intracranial hemorrhage
DISEASE
. This wasfollowed serially with CT scans and there was no progressionof the
bleeding
DISEASE
. The
bleeding
DISEASE
was thought to be secondary toher severe
coagulopathy
DISEASE
and
thrombocytopenia
DISEASE
in the settingof her instrumentation. She was started on Keppra for
seizure
DISEASE
prophylaxis to finish a 10-day course. On [**2187-11-12**]the patient was extubated and her neurologic exam was notablefor response to voice and opening of her eyes. She was movingher left upper extremity and her right lower extremity with2/5 strength and had minimal movement in her right upperextremity and left lower extremity not following thepredicted neurologic pattern if this was a
deficit
DISEASE
associatedwith her
intracranial bleeding
DISEASE
.In terms of her respiratory status it is noted that thepatient required full ventilatory support and was extubatedon [**2187-11-12**]. She initially did well but secondaryto what was thought to be
pulmonary edema
DISEASE
requiredreintubation on [**2187-11-13**] after failure of noninvasivepositive pressure ventilation. She had some degree of whatappeared to be an
ARDS-type reaction
DISEASE
or transfusion-associated
lung injury
DISEASE
requiring high amounts of PEEP andoxygenation during the initial days of her intensive careunit stay. This resolved over the course of the next severaldays with diuresis and supportive therapy.In terms of her cardiovascular status the patient initiallyhad blood pressure support with the use of vasopressors inorder to minimize her intravascular volume which was thoughtto exacerbate her
cerebral edema
DISEASE
. The vasopressors wereweaned by ICU day 6 and there was no further requirement forthis. There were no significant
dysrhythmias
DISEASE
.The patient initially thought to most certainly requireliver transplantation spontaneously improved in terms of herliver function over the course of her 2 weeks in theintensive care unit. This was evidenced by progressiveability to metabolize her lactate stabilization of her bloodsugars and autocorrection of her
coagulopathy
DISEASE
. By the timeof her transfer while she continued to have a
hyperbilirubinemia
DISEASE
her transaminases had completelynormalized. A Dobbhoff feeding tube was in place for post-pyloric tube feedings. The patient's transaminases wereelevatedAdmission Date: [**2187-10-29**] Discharge Date: [**2187-11-23**]Date of Birth: [**2135-10-28**] Sex: FService: MEDICINE
Allergies
DISEASE
:BactrimAttending:[**First Name3 (LF) 1936**]Chief Complaint:
Acute liver failure
DISEASE
Major Surgical or Invasive Procedure:Intubation with extubation on [**2187-11-16**]Hemodialysis
Intracranial bolt
DISEASE
placement [**10-31**] and removal [**2187-11-5**]History of Present Illness:Pt is a 52F with
OCD
DISEASE
(stable recently but h/o OD
anorexia
DISEASE
andalcohol use in past) ileostomy
GERD
DISEASE
with delayed gastricemptying who presented to [**Hospital3 3765**] on [**10-28**] with
nausea
DISEASE
and
dizziness
DISEASE
. There she was initially dx'd with
dehydration
DISEASE
ARF
DISEASE
and
UTI
DISEASE
but then found to have ALT of 25370 and of AST11490 total bili of 2.0 INR of 4.0 Cr of 3.0. She wastransferred to [**Hospital1 18**]..She had been having
fevers
DISEASE
for Admission Date: [**2148-8-7**] Discharge Date: [**2148-8-20**]Date of Birth: [**2094-7-27**] Sex: FService: NEUROSURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1835**]Chief Complaint:
Meningioma
DISEASE
.Major Surgical or Invasive Procedure:Suboccipital craniotomy for resection of
tumor
DISEASE
.History of Present Illness:Patient is a 53F seen today in consultation for a Midlineposterior fossa extra-axial mass most likely consistent with a
meningioma
DISEASE
(DD: dural based met). the lesion is measuring2.2x1.2cm. She was initialy being seen in the orthopedic clinics/p left TKR [**1-/2148**] and complained of a Admission Date: [**2147-11-8**] Discharge Date: [**2147-11-27**]Service: [**Hospital1 139**].CHIEF COMPLAINT:
Gastrointestinal bleeding bacteremia
DISEASE
and
fungemia
DISEASE
.HISTORY OF THE PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-oldmale with multiple medical problems with the past medicalhistory significant for
gastric cancer
DISEASE
status post resectionwith vagotomy
prostate cancer
DISEASE
with likely bony
metastasis
DISEASE
recurrent aspiration
pneumonia
DISEASE
chronic
anemia
DISEASE
questionablehistory of
gastrointestinal bleeds
DISEASE
with severalesophagogastroduodenoscopies in the past showing Candidal
esophagitis
DISEASE
with nonbleeding
fundal polyps
DISEASE
and
dementia
DISEASE
thought to be secondary to
Alzheimer disease
DISEASE
. The patientwas admitted to [**Hospital1 69**] on[**9-30**] with a 30 pound
weight loss
DISEASE
over severalmonths and acute and chronic mental-status decline and
pneumonia
DISEASE
. He was treated for his
pneumonia
DISEASE
with Levaquinand then changed to Azithromycin and sent to Core forrehabilitation on [**2147-10-4**]. While there thepatient had continued treatment of
pneumonia
DISEASE
and anesophagogastroduodenoscopy was done on [**10-16**] whichshowed
esophagitis
DISEASE
with nonbleeding
fundal polyp
DISEASE
. He hadbeen started on TPN for unknown number of days which wasbeing given through a PIC line and on [**10-28**] grewout MRSA from blood and E. coli from urine. The patient wasstarted on Cefepime on [**2147-10-30**]. On [**2147-11-4**] the patient was febrile to 102 degrees and repeat bloodcultures at that time showed gram-positive cocci in pairs andchains. This grew from two sites including the patient's PICline. In addition the patient's blood grew out yeast whichhad not been speciated at the time of admission. The patientwas started on Vancomycin and Fluconazole on [**2147-11-4**] at [**Hospital1 5042**]. The patient now presents to [**Hospital1 346**] with black-tarry stools which havebeen going on for an unknown number of days at [**Hospital1 5042**]. Therewas no history of
emesis
DISEASE
or bright red blood per rectum. Thepatient's hematocrit was 19 on [**2147-11-6**]. He wasgiven two units of packed red blood cells at that time withrepeat hematocrit on [**11-8**] still at 19. The patientwas therefore transferred to [**Hospital1 188**] for further evaluation and treatment.In the emergency department here the patient's temperaturewas 100.7 rectally and he was found to be
hypotensive
DISEASE
with asystolic blood pressure in the 80sAdmission Date: [**2147-11-8**] Discharge Date: [**2147-12-3**]Service: [**Hospital1 **]HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year-old Russianmale with a history of
gastric and prostate cancer anemia
DISEASE
and
esophagitis
DISEASE
who was transferred from the nursing home tothe MICU with a
gastrointestinal bleed fungemia
DISEASE
and
bacteremia
DISEASE
. He had a very complicated medical courseincluding treatment for his
fungemia
DISEASE
and
bacteremia
DISEASE
as wellas for aspiration
pneumonia
DISEASE
given his poor mental status andfrequent aspirations. Despite multiple courses of broadspectrum antibiotics and other supportive measures heeventually succumbed to one of his aspiration
pneumonias
DISEASE
onthe [**11-2**] and passed away. [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**] M.D. [**MD Number(1) 5046**]Dictated By:[**Name8 (MD) 1552**]MEDQUIST36D: [**2147-12-16**] 18:20T: [**2147-12-20**] 14:46JOB#: [**Job Number 5048**]Admission Date: [**2168-7-16**] Discharge Date: [**2168-7-20**]Date of Birth: [**2106-10-15**] Sex: MService: MEDICINE
Allergies
DISEASE
:Purinethol / RemicadeAttending:[**First Name3 (LF) 2297**]Chief Complaint:BRBPRMajor Surgical or Invasive Procedure:Upper and lower endoscopy ([**2168-7-17**])History of Present Illness:HMED ATTG ADMIT NOTE.DATE [**2168-7-16**]TIME 2300.PCP [**Name9 (PRE) **]GI [**Name9 (PRE) **].61 yo M with
Crohn's disease
DISEASE
on prednisone s/p total colectomyin [**2147**] complicated by
perirectal abscess
DISEASE
s/p internal drainage[**9-22**] and newly diagnosed
DVT
DISEASE
[**5-24**] on coumadin who presents tothe ED with BRBPR..Patient reports 16
bloody bowel movements
DISEASE
yesterday ([**2168-7-15**]).Went to see PCP ([**Doctor Last Name 2472**]) and INR was 4.7. Patient instructedto hold coumadin. Went home overnight had multiple bloody
bowel movements
DISEASE
. This am had 3 episodes of
syncope
DISEASE
where heawoke on his bathroom floor denies any
head trauma
DISEASE
. Lastbloody BM was around [**1-15**] pm today. No
abdominal pain
DISEASE
(haschronic rectal pain). No
fevers nausea or vomiting
DISEASE
.Lightheadedness with standing. Denies any cp or sob. Endorsesmild
dysuria
DISEASE
s/p TURP 4 weeks ago..Went to [**Hospital1 **]-[**Location (un) 620**] ED today and found to have INR 5.4 and Hct of27 (hct two weeks ago at [**Hospital1 18**] was 36.8). CT abdomen performedwhich showed a 15 mm perirectal abscess connected to rightlateral anal
fistula
DISEASE
slightly enlarged from prior MRI in[**Month (only) 956**] of this year at which time abscess was less organized. Given 4L of NS. Anoscopic exam performed in ED which showedmoderate maceration of perianal region but no gross
bleeding
DISEASE
.Heme positive. No fistulas or fissures. Reported that patientreceived iv cipro/flagyl however patient states this was nevergiven..Transferred to [**Hospital1 18**] ED: 97.0 72P 104/76 16 100%RAAdmission Date: [**2184-1-12**] Discharge Date: [**2184-1-16**]Date of Birth: [**2116-6-9**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Penicillins / TimopticAttending:[**First Name3 (LF) 922**]Chief Complaint:
Dyspnea
DISEASE
on exertionMajor Surgical or Invasive Procedure:[**2183-1-11**] - Coronary bypass grafting x5: Left internal mammaryartery to left anterior descending coronaryAdmission Date: [**2128-9-6**] Discharge Date: [**2128-9-14**]Service:HISTORY OF PRESENT ILLNESS: The patient is a 70-year-oldpatient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] withknown mitral valve and
3-vessel disease
DISEASE
referred for cardiaccatheterization to evaluate his aortic valve.The patient had never experienced
chest pain
DISEASE
or shortness ofbreath in the past. In about [**2116**] the patient had anexercise treadmill test followed by a cardiac catheterizationwhich showed 50% proximal left anterior descending artery60% distal left anterior descending artery 40% proximalright coronary artery 70% mid right coronary artery andsome degree of
mitral regurgitation
DISEASE
which was subsequentlyfollowed by an echocardiogram in [**2128-7-23**]. The patienthad an exercise tolerance test which showed inferior andseptal
ischemia
DISEASE
with an ejection fraction of 65%.Cardiac catheterization done on [**2128-8-13**] showed 60%circumflex proximal 90% distal circumflex 80% proximalright coronary artery with an 80% distal right coronaryartery 90% posterior descending artery 70% left main and40% proximal left anterior descending artery and 70% midleft anterior descending artery.The patient had an echocardiogram done by a localcardiologist which showed a question of significant aorticstenosis that was difficult to assess due to
calcification
DISEASE
.Catheterization done on the day of admission demonstrated anaortic valve area of 2.0 cm2 with 16 mmHg of pressure and awedge pressure of 8.PAST MEDICAL HISTORY: (The patient's past medical history issignificant for)1. Chronic
renal insufficiency
DISEASE
.2. Cyst on spine at L5Admission Date: [**2178-7-13**] Discharge Date: [**2178-7-16**]Date of Birth: [**2113-11-13**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Bee PollensAttending:[**First Name3 (LF) 1283**]Chief Complaint:decreased exercise toleranceMajor Surgical or Invasive Procedure:Minimally invasive mitral valve repair w/annuloplasty bandHistory of Present Illness:64 y/o male w/known
MVP
DISEASE
decreasing exercise tolerance followedby echo. Recently with severe
MR
DISEASE
decreased LVEF.Past Medical History:MIMR/MVP
hepercholesterolemia
DISEASE
HTN
DISEASE
BPHs/p tonsillectomys/p repair of deviated septumSocial History:marriednever smoked2 glasses wine/dayno
drug abuse
DISEASE
historyFamily History:mother died of MI at age 55father died of MI age 62Physical Exam:unremarkable pre-opPertinent Results:[**2178-7-16**] 07:20AM BLOOD WBC-8.1 RBC-2.91* Hgb-9.1* Hct-26.6*MCV-92 MCH-31.3 MCHC-34.2 RDW-14.1 Plt Ct-113*[**2178-7-16**] 07:20AM BLOOD Plt Ct-113*[**2178-7-15**] 06:40AM BLOOD Glucose-114* UreaN-22*
Creat-0.8
DISEASE
Na-136K-4.4 Cl-105 HCO3-27 AnGap-8Brief Hospital Course:Mr. [**Known lastname 2137**] was admitted to the pre-op holding area on [**2178-7-13**]and taken to the operating room where he underwent a minimallyinvasive mitral valve repair w/annuloplasty band.Post-operatively he was taken to the cardiac surgery recoveryunit. He was weaned from mechanical ventilation and extubatedthe evening of surgery. He was transferred to the telemetryfloor on POD # 1. His chest tubes were removed without issue.He worked with physical therapy to improve his strength andmobility. He has remained hemodynamically stable and wasdischarged home on postoperative day three. He will follow-upwith Dr. [**Last Name (STitle) 1290**] his cardiologist and his primary carephysician as an outpatient.Medications on Admission:ASA 81'Lipitor 80'Lisinopril 40'Terazosin 5'Proscar 5'Zetia 10'Discharge Medications:1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2times a day).Disp:*60 Capsule(s)* Refills:*2*2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2times a day).Disp:*60 Tablet(s)* Refills:*2*3. Aspirin 81 mg Tablet Delayed Release (E.C.) Sig: One (1)Tablet Delayed Release (E.C.) PO DAILY (Daily).Disp:*30 Tablet Delayed Release (E.C.)(s)* Refills:*2*4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets POQ4H (every 4 hours) as needed for
pain
DISEASE
.Disp:*40 Tablet(s)* Refills:*0*5. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.Disp:*30 Tablet(s)* Refills:*2*6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).Disp:*30 Tablet(s)* Refills:*2*7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).Disp:*30 Tablet(s)* Refills:*2*8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6hours) for 2 weeks: then Q 6 hours prn
pain
DISEASE
.Disp:*90 Tablet(s)* Refills:*0*9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a dayfor 7 days.Disp:*14 Tablet(s)* Refills:*0*10. Potassium Chloride 10 mEq Capsule Sustained Release Sig:Two (2) Capsule Sustained Release PO Q12H (every 12 hours) for7 days.Disp:*28 Capsule Sustained Release(s)* Refills:*0*11. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (atbedtime).Disp:*30 Capsule(s)* Refills:*2*12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).Disp:*30 Tablet(s)* Refills:*2*13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice aday.Disp:*60 Tablet(s)* Refills:*2*Discharge Disposition:Home With ServiceFacility:[**Hospital3 **] VNADischarge Diagnosis:MR s/p min inv MV Repair(#34 annuloplasty bandPMH: MR Admission Date: [**2137-10-31**] Discharge Date: [**2137-11-5**]Date of Birth: [**2090-7-30**] Sex: FService: MEDICINE
Allergies
DISEASE
:Morphine / IodineAdmission Date: [**2137-12-25**] Discharge Date: [**2138-1-1**]Date of Birth: [**2090-7-30**] Sex: FService: MEDICINE
Allergies
DISEASE
:Morphine / IodineAdmission Date: [**2138-1-24**] Discharge Date: [**2138-2-7**]Date of Birth: [**2090-7-30**] Sex: FService: MEDICINE
Allergies
DISEASE
:Morphine / IodineAdmission Date: [**2155-1-2**] Discharge Date: [**2155-1-6**]Date of Birth: [**2074-12-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 898**]Chief Complaint:
Dyspnea
DISEASE
on exertionMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:80 year old male with h/o
COPD CHF
DISEASE
sent in by PCP to evaluate
hypoxemia
DISEASE
. His baseline O2 sat is 92% and he was noted to be78%
RA
DISEASE
at his PCP's office and satting in the 86% 4Ln.c. in theED. His CXR with
pulmonary congestion
DISEASE
and RLL
pneumonia
DISEASE
.Patient states for the past week he has had increasing
dyspnea
DISEASE
on exertion and also with some
dizziness
DISEASE
and
nausea
DISEASE
withexertion. Two days prior to admission he states he was sandingfloors with his son wearing a mask and noticed the symptoms tobe more prominent after this. He was initially admitted to theMICU as he was started on bipap in the ED. In the ICU hereceived nebs levofloxacin for his
pneumonia
DISEASE
and diuresed himwith lasix 20mg iv prn. He diuresed 2.4 L off since admission(24 hrs). He was transitioned quickly off bipap and onto 40%face mask. ABG on [**1-3**] a.m. 7.34/61/81..He is currently on face mask states his breathing is much morecomfortable. He denies
fevers cough chest pain
DISEASE
abd
pain
DISEASE
leg
swelling
DISEASE
.Past Medical History:
COPD
DISEASE
(last PFTs [**2148**] FEV1/FVC 98% FEV1 55)
Coronary artery disease
DISEASE
CHF
DISEASE
(last echo [**2148**] showed preserved EF Admission Date: [**2158-12-12**] Discharge Date: [**2158-12-19**]Date of Birth: [**2074-12-4**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 4679**]Chief Complaint:Right lower lobe lung noduleMajor Surgical or Invasive Procedure:[**2158-12-12**]OPERATIONS:1. Right video-assisted thoracic surgery (VATS) converted to right thoracotomy superior segmentectomy of right lower lobe.2. Mediastinal lymph node dissection.History of Present Illness:Mr. [**Known lastname 5066**] is an 84 year old gentleman who was admitted intothe hospital for surgical management of a right lower lobe mass.He had a chest CT scan on [**9-14**] that showed a 24 x 28 mmnoncalcified nodule in the superior segmentof right lower lobe. He denied any
shortness of breath
DISEASE
prior toadmission. He did admit to
intermittent productive cough
DISEASE
priorto admission but no persistent
hemoptysis
DISEASE
. He was admittedfollowing a right video assisted thoracostomy superiorsegmentectomy.Past Medical History:
COPD
DISEASE
(last PFTs [**2148**] FEV1/FVC 98% FEV1 55)
Coronary artery disease
DISEASE
CHF
DISEASE
(last echo [**2148**] showed preserved EF Admission Date: [**2159-8-1**] Discharge Date: [**2159-8-7**]Date of Birth: [**2074-12-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 2641**]Chief Complaint:
Dyspnea
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:84M h/o
COPD
DISEASE
dCHF AF AS valve area 0.7 s/p superiorsegmentectomy of right lower lobe [**12/2158**] c/o
dyspnea
DISEASE
and
cough
DISEASE
..He was seen initially at [**Hospital 4628**] hospital where sats noted ashigh 80s-low 90s on 3L with borderline trop (0.08 which is[**Hospital1 5075**] reference cutoff). BNP there 734 by report. CXRthere also showed pna but he was not treated there. Given tropcards at OSH was called however defferred cath since INR 3.5.Patient was given aspirin steroids and Lasix 40mg (approx 5hours PTA here). Also had CT head/cspine (both negative) forfall 1 week ago..On arrival to the ED at [**Hospital1 18**] VS were: 98.6 76 107/57 16hypoxic in the mid 80s on 3 L but mentating very well and sayshe feels relatively well. Lungs had minimal crackles atbilateral bases..Creatinine 1.2 (baseline 0.9-1.0). CBC 8.5 95% N/37.8/312. UAwas negative. ABG was 7.38/33/132 on NRB 100%. Lactate 1.5.INR 3.6. Trop was 0.07. CXR consistent with
pneumonia
DISEASE
. EDresident thinks no ST changes on EKG. Blood cultures were sent.Patient was discussed with Dr. [**Last Name (STitle) 5076**] who agrees that this may be
pneumonia
DISEASE
and demand and recommends diuresis and that he mayneed cath if does not improve medically. He was givenLevofloxacin 750mg before transfer to ICU..VS on transfer: afebrile (99) 71 117/70s mid 20s 98% on NRB. BP low to mid 90s when arrived per ED resident. Access is 218G IV. Tried titrating down on oxygen a couple of hours ago anddid not tolerate it..On the floor history is obtained from the patient and his son.They state that since his wife's passing on [**7-14**] he has not beendoing well but denies
dyspnea
DISEASE
or CP during that time. Hisdaughter moved from [**Name (NI) 108**] and has been living with him andhelping with his medications. He has not missed any medicationsnor had any changes except an antidepressant. Patient did have afall [**7-21**] when he had been drinking wine and fell over a diningroom chair after he tripped. He was evaluated in the ED the nextday and had neg CT scans. Day prior to admission he was doingwell did yard work and then took 3 cans of prune juice becauseof
constipation
DISEASE
. (Children report he takes a lot of OTC stoolmeds.) He then had multiple unknown number of episodes of
diarrhea
DISEASE
yesterday and last night. No
fevers
DISEASE
or
chills
DISEASE
no
cough
DISEASE
. His son states that the patient told him that he awoke at4am with
pain
DISEASE
up and down his epigastrum which resolved. No back
pain
DISEASE
. He then went back to bed and his son found him thismorning at 8:30am sitting in a chair and pale. He was unsteadyand not very responsive. No history of
stroke
DISEASE
or
CVA
DISEASE
.Currently he states that he feels much improved though has beendyspneic for the past day since doing the yardwork. No chest
pain
DISEASE
at all. No
swelling
DISEASE
. Admission Date: [**2159-8-17**] Discharge Date: [**2159-8-22**]Date of Birth: [**2074-12-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 983**]Chief Complaint:
Lethargy hypoxia
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:84M h/o
COPD
DISEASE
dCHF
AF
DISEASE
AS (valve area 0.8cm2) s/p superiorsegmentectomy of right lower lobe [**12/2158**] now presenting with
lethargy
DISEASE
and
hypoxia
DISEASE
.The patient's family reports increasing
lethargy
DISEASE
for the past 2days and was found to be hypoxic to the 60's by the VNA. Hisdaughter had called his PCP [**Last Name (NamePattern4) **] [**8-13**] for
weight gain
DISEASE
but thedecision was made not to increase the Lasix at that time. Hedenies
shortness of breath chest pain
DISEASE
fevers/chills
cough
DISEASE
nausea vomiting abdominal pain
DISEASE
.The patient was admitted [**Date range (1) 5081**] for community acquired
pneumonia
DISEASE
and acute on chronic diastolic CHF. During thatadmission the patient was diuresed with Lasix in the MICU forhis acute
CHF
DISEASE
exacerbation. However the patient was called outto the floor and prior to discharge his Lasix dose wasdecreased from 40 mg [**Hospital1 **] to 40 mg every other day for anelevated bicarb on labs which was attributed to contraction
alkalosis
DISEASE
. His Spironolactone 25 mg daily was also discontinuedduring that admission for unclear reasons. He was treated forthe
pneumonia
DISEASE
with Levofloxacin x7 days and a prednisone burstand PO2 was 95% on 3L at time of discharge with ambulatory satsof 85%
RA
DISEASE
unknown ambulatory PO2 on 3L NC. He has been onsupplemental O2 at 2L NC since discharge from his recenthospitalization.In the ED initial VS were: 117/57 59 18 93% BIPAP (fiO230%)Exam: shallow breathing Admission Date: [**2130-10-23**] Discharge Date: [**2130-10-24**]Date of Birth: [**2083-4-10**] Sex: MService: SURGERY
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 695**]Chief Complaint:
Hypotension sepsis
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:47M with
chronic hepatitis B
DISEASE
virus associated
cirrhosis
DISEASE
anddelta
hepatitis
DISEASE
suprainfection on the liver transplant list(baseline MELD 27). EMS was called this morning at 4am for 3days of worsening
abdominal pain
DISEASE
double vision and weakness.Upon arrival to his home: HR 100 BP 60/30's O2 sats84% FS 46. Oriented x 4. Taken to [**Hospital 1474**] Hospital forstabilization and the transplant center was notified.At [**Hospital1 1474**] he was started on lactulose Neo-Synephrineoctreotide and midodrine he was intubated started on a D10Wgtt. Once a bed was available he was transferred to the [**Hospital1 18**]SICU.Past Medical History:-
congenital Hepatitis B
DISEASE
- Hep D positivity-
Cirrhosis
DISEASE
decompensated by
ascites
DISEASE
and
jaundice
DISEASE
-
Anemia
DISEASE
-
Psoriasis
DISEASE
- Internal hemorrhoids.Social History:Married 2 children 49 worked as social case manager in thepast now works as PCA 8h per week. Has not smoked or drank EtOHsince age of 15. No IVDU.. .Family History:Mother: HBV DMPhysical Exam:PE: Neo 0.35 Vaso 2.4 Phenylephrine 1.5 112 91/44 CVP 17 2796% CMV 100% Admission Date: [**2169-9-1**] Discharge Date: [**2169-9-2**]Date of Birth: [**2119-6-16**] Sex: MService: NEUROSURGERY
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 1271**]Chief Complaint:noneMajor Surgical or Invasive Procedure:noneHistory of Present Illness:The patient is a 50 year old right-handed man presentingwith a few weeks of progressively worsening
headache
DISEASE
. He rarelyhas
headaches
DISEASE
(certainly no
migraine
DISEASE
or recurrent severe
headaches
DISEASE
) but he started having a
headache
DISEASE
after sustaining a
head injury
DISEASE
on [**2169-8-3**]. He was driving his car and wasbroad-sided on the passenger side causing him to hit the leftside of his head on the side window. He did not loseconsciousness and was not stunned but actually was able todrivehome (after the rather unpleasant other driver confronted him).He had no external evidence of
head trauma
DISEASE
. He started having a
bitemporal vertex neck
DISEASE
and back achy that was predominantlypulsatile sometimes with a stabbing Admission Date: [**2169-9-11**] Discharge Date: [**2169-9-13**]Date of Birth: [**2119-6-16**] Sex: MService: NEUROSURGERY
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 5084**]Chief Complaint:
headaches
DISEASE
Major Surgical or Invasive Procedure:[**2169-9-11**]: right temporal craniotomy and resection of lesionHistory of Present Illness:Pt was seen a week prior to this admission for
headaches
DISEASE
. workup at that time revealed a right temporal lesion. It wasrecommended that the patient undergo surgical intervention. Herecommended discharge home and to follow up electively. He nowpresents electively for craniotomy and resectionPast Medical History:[] Neurologic - Possible/questionable
seizures
DISEASE
(lightheadedfatigue [**Last Name (un) 5083**] vu Admission Date: [**2182-1-19**] Discharge Date: [**2155-2-24**]Service:HISTORY OF PRESENT ILLNESS: The patient is an 88-year-oldfemale with a history of
coronary artery disease
DISEASE
now with
bradycardia
DISEASE
. He had an episode of
dizziness
DISEASE
when walkingtoday. His wife took his pulse and noticed it was Admission Date: [**2131-6-17**] Discharge Date: [**2131-6-19**]Date of Birth: [**2055-3-21**] Sex: FService: MEDICINE
Allergies
DISEASE
:Hydrochlorothiazide / Norvasc / Zestril / Bactrim DsAttending:[**First Name3 (LF) 1990**]Chief Complaint:inability to swallowMajor Surgical or Invasive Procedure:EGD and intubation for EGDHistory of Present Illness:76 yo woman with Schatzki's ring s/p dilation in [**2129**] with nosymptoms until 1 mo ago noticed increased time to pass foodbelow LES (15 minutes) but night prior to presentation developedinability to pass food/liquids one hour after eating a meal offish and chinese noodles.In the ED: She was given glucagon nitro and zofran. GI wasconsulted and requested ICU admission for monitoring planningEGD for day of admission.Past Medical History:
hypertension
DISEASE
schatzki's ring
anemia
DISEASE
s/p hysterectomy
depression
DISEASE
Social History:remote (quit 30-40 years ago) smoking history drinks a glass ofwine with dinner lives with husband retired.Family History:noncontributoryPhysical Exam:Flowsheet Data as of [**2131-6-17**] 06:02 PMVital SignsAdmission Date: [**2149-2-2**] Discharge Date: [**2149-2-6**]Service: SURGERY
Allergies
DISEASE
:Golytely / MorphineAttending:[**First Name3 (LF) 974**]Chief Complaint:
Nausea
DISEASE
and
Vomiting
DISEASE
Inability to speak x minutesMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:83F with h/o seven prior strokes HTN NIDDM vertigo Bell's
Palsy
DISEASE
who reports a one day history of
nausea
DISEASE
and
vomiting
DISEASE
complicated by a brief episode of weakness/alteredresponsiveness and inability to speak while sitting on toilet.This was witnessed by her daughter.Past Medical History:history of CADAdmission Date: [**2101-9-7**] Discharge Date: [**2101-9-13**]Date of Birth: [**2034-11-19**] Sex: FService: [**Company 191**]CHIEF COMPLAINT: Shortness of breath.HISTORY OF THE PRESENT ILLNESS: The patient is a 66-year-oldwoman who has a past medical history dominated by severe
chronic obstructive pulmonary disease
DISEASE
with
OSA
DISEASE
as well asCAD and
CHF
DISEASE
. The patient was brought to the emergencydepartment this AM by her son after she awakened with severe
shortness of breath
DISEASE
. She was discharged from [**Hospital1 1501**] ([**Hospital1 2670**]in [**Location (un) 5089**]). Two weeks ago doing well overall withincreased activity level and no
chest pain
DISEASE
or resting
dyspnea
DISEASE
. She denied recent
fever
DISEASE
of
chills
DISEASE
. She has a
cough
DISEASE
at baseline.She was last hospitalized in late [**Month (only) 216**] with
fatigue
DISEASE
andlater chest painAdmission Date: [**2173-12-8**] Discharge Date: [**2173-12-22**]Date of Birth: [**2103-2-21**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 165**]Chief Complaint:
Shortness of breath
DISEASE
Major Surgical or Invasive Procedure:[**2173-12-17**] - Pericardectomy[**2173-12-14**] - Cardiac Catheterization[**2173-12-10**] - Pericardial Window[**2173-12-9**] - Cardiac CatheterizationHistory of Present Illness:The patient is a 70 year old woman with history of PAF
hypertension
DISEASE
who presents with
shortness of breath
DISEASE
. The patienthas had some sob and
cough
DISEASE
since [**2173-11-15**] when she was admittedto St E with
chest pain
DISEASE
(sharp
substernal pleuritic
DISEASE
non-positional) shortness of breath and fatigue
DISEASE
found to be innew afib and started on coumadin. At that time an ETT wasnegative and she completed a r/o MI. She was hypoxic at thattime requiring 4-6L of nasal cannula. On [**2173-11-18**] she had a CTAchest that showed small bilateral
pleural effusions
DISEASE
andbilateral lower lobe atelectasis w/o evidence for PE. On [**2173-11-19**]she had a tte efAdmission Date: [**2140-7-27**] Discharge Date: [**2140-8-1**]Date of Birth: [**2085-3-8**] Sex: MService: CSUCHIEF COMPLAINT: This is a 55 year old patient of Dr. [**First Name8 (NamePattern2) **][**Last Name (NamePattern1) 2450**] referred following cardiac catheterization for coronaryartery bypass grafting.HISTORY OF PRESENT ILLNESS: The patient was admitted to [**Hospital1 1444**] with
chest pain
DISEASE
in [**Month (only) 404**].He ruled out for a
myocardial infarction
DISEASE
. His
pain
DISEASE
wasthought not to be cardiac at that time. The patientpresented again [**2140-7-16**] with complaints of
chest pain
DISEASE
timestwo weeks.
Chest pain
DISEASE
occurred with exertion andoccasionally at rest. He ruled out for a myocardial
infarction
DISEASE
and did not have any ischemic electrocardiographicchanges. He had a stress test on [**2140-7-18**] stopped becauseof
chest pain
DISEASE
and ST
depression
DISEASE
in leads I and V6. Hisrhythm was sinus. Nuclear imaging revealed inferoapicalreversible defects with an ejection fraction of 55 percent.Following stress test the patient had a cardiaccatheterization done on [**2140-7-25**] which revealed two vessel
coronary artery disease
DISEASE
. Please see catheterization reportfor full details. In summary the patient had extremelyshort left main. Left anterior descending coronary arterywas diffusely diseased with 50 percent proximal stenosis anda 95 percent distal lesion. D1 was diffusely diseased. Thecircumflex had a 30 percent proximal large obtuse marginalhad 40 percent stenosis at the origin and the right coronaryartery was totally occluded proximally.PAST MEDICAL HISTORY: Hypertension.
Hyperlipidemia
DISEASE
.
Diabetes mellitus
DISEASE
.
Gastroesophageal reflux disease
DISEASE
.Unrepaired
ventricular septal defect
DISEASE
.PAST SURGICAL HISTORY: Rectosigmoid
polyp
DISEASE
removal.Knee surgery times four.Appendectomy.MEDICATIONS ON ADMISSION:1. Metformin 500 mg twice a day.2. Prazocin 2 mg twice a day.3. Metoprolol 100 mg twice a day.4. Glyburide 5 mg twice a day.5. Mavik 6 mg p.o. once daily.6. Protonix 40 mg twice a day.7. Nifedipine XR 90 mg once daily.8. Aspirin 81 mg once daily.9. Niacin 500 mg once daily.LABORATORY DATA: White blood cell count 6.4 hematocrit40.8 platelet count 213000. Prothrombin time 12.0 partialthromboplastin time 26.8 INR 1.0. Urinalysis is negative.Sodium 132 potassium 4.9 chloride 101 CO2 22 blood ureanitrogen 26 creatinine 1.3 glucose 210 ALT 25 AST 27alkaline phosphatase 129 amylase 67 total bilirubin 0.6albumin 4.0 cholesterol 198.Chest x-ray showed no radiographic evidence for acutecardiopulmonary process.SOCIAL HISTORY: The patient is married. He works forAmerican Alliance on the loading docks. He is also a driverfor the Israeli Consulate.HOSPITAL COURSE: As stated previously the patient was adirect admission to the operating room on [**2140-7-27**]. Pleasesee the operating room report for full details. In summarythe patient had coronary artery bypass grafting times fourwith the left internal mammary artery to the left anteriordescending coronary artery saphenous vein graft to theobtuse marginal two saphenous vein graft to diagonalsaphenous vein graft to the posterior descending coronaryartery. His bypass time was 78 minutes with a cross clamptime of 67 minutes. He tolerated the operation well and wastransferred from the operating room to CardiothoracicIntensive Care Unit. At that time he was in sinus rhythm at80 beats per minute. He had a mean arterial pressure of 61with a PAD of 16. He had Neo-Synephrine at 0.3mcg/kg/minute insulin at two units per hour and Propofol at30 mcg/kg/minute. The patient did well in the immediatepostoperative period. His anesthesia was reversed. He wasweaned from the ventilator and successfully extubated. Heremained hemodynamically stable overnight. On postoperativeday number one he was weaned from all cardioactiveintravenous medications. His Swan-Ganz line was discontinuedand his chest tubes were removed. However on a follow-upchest x-ray the patient was noted to have a
pneumothorax
DISEASE
andhe was therefore kept in the Intensive Care Unit forpulmonary monitoring. Postoperative day number two thepatient continued to have periods of
desaturation
DISEASE
with littleor minimal activity. His chest x-ray showed a small apicalleft
pneumothorax
DISEASE
as well as
atelectasis
DISEASE
. He continued tohave periods where he would desaturate and he was kept in theIntensive Care Unit again for vigorous chest physical therapyand pulmonary toilet. On postoperative day number three thepatient continued to do well. With increasing activity andchest physical therapy he no longer had periods of
desaturation
DISEASE
and therefore he was transferred to the floorfor continuing postoperative care and cardiac rehabilitation.At that time his temporary pacing wires were removed. Onceon the floor the patient had an uneventful hospital courseand on postoperative day number four the patient's activitylevel had progressed enough that he was considered ready fordischarge to home with visiting nurses. At that time thepatient's physical examination was as follows: Vital signsshowed temperature 98.9 heart rate 82 sinus rhythm bloodpressure 110/56 respiratory rate 18 oxygen saturation 96percent in room air. Laboratories showed a white blood cellcount 6.1 hematocrit 24.9 platelet count 293000. Sodium140 potassium 4.5 chloride 103 CO2 30 blood urea nitrogen21 creatinine 1.2 glucose 105 weight preoperatively 94.9kilograms and at discharge 100.3 kilograms. On physicalexamination neurologically alert and oriented times threemoves all extremities nonfocal examination. Respiratory -diminished breath sounds in the left base and otherwise clearto auscultation. Cardiovascular is regular rate and rhythmS1 and S2 with no murmurs. The sternum is stable. Theincision with staples open to air clean and dry. Theabdomen is soft nontender nondistended with normoactivebowel sounds. Extremities are warm and well perfused withone plus
edema
DISEASE
right saphenous vein graft harvest site withSteri-Strips with large
bullae
DISEASE
underneath the Steri-Strips.MEDICATIONS ON DISCHARGE:1. Metoprolol 75 mg twice a day.2. Ferrous Sulfate 325 mg once daily.3. Vitamin C 500 mg twice a day.4. Metformin 500 mg twice a day.5. Glyburide 10 mg q.a.m. and 5 mg q.p.m.6. Plavix 75 mg once daily.7. Aspirin 325 mg once daily.8. Protonix 40 mg once daily.9. Niacin 500 mg once daily.10. Lasix 20 mg twice a day times two weeks.11. Potassium Chloride 20 mEq twice a day times two weeks.12. Dilaudid 2 to 4 mg p.o. q4-6hours p.r.n.DISCHARGE DIAGNOSES: Coronary
artery disease
DISEASE
status postcoronary artery bypass grafting times four with left internalmammary artery to the left anterior descending coronaryartery saphenous vein graft to obtuse marginal saphenousvein graft to diagonal and saphenous vein graft to posteriordescending coronary artery.
Hypertension
DISEASE
.
Chronic renal insufficiency
DISEASE
.
Hyperlipidemia
DISEASE
.
Gastroesophageal reflux disease
DISEASE
.Knee surgery times four.Rectosigmoid
polyp
DISEASE
removal.Appendectomy.
Diabetes mellitus
DISEASE
type 2.CONDITION ON DISCHARGE: Good.DISCHARGE STATUS: He is to be discharged home with visitingnurses.FOLLOW UP: He is to follow-up in the [**Hospital 409**] Clinic in twoweeks follow-up with Dr. [**Last Name (STitle) 2450**] in two to three weeks andfollow-up with Dr. [**Last Name (STitle) **] in four weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**] [**MD Number(1) 1715**]Dictated By:[**Last Name (NamePattern4) 1718**]MEDQUIST36D: [**2140-8-1**] 16:51:14T: [**2140-8-1**] 18:20:00Job#: [**Job Number 5107**]Admission Date: [**2140-7-15**] Discharge Date: [**2140-7-17**]Date of Birth: [**2077-7-22**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 1515**]Chief Complaint:
Chest Pain
DISEASE
Major Surgical or Invasive Procedure:Cardiac Catheterization with 3 BMS placed in RCAHistory of Present Illness:Mr [**Known lastname 5108**] is a 62 year-old man with past medical history of
HIV/AIDS hyperlipidemia
DISEASE
former heavy tobacco use and prostate
cancer
DISEASE
s/p brachytherapy who was transferred from [**Hospital1 5109**] for STEMI. He reports three hours of substernal chest
pain
DISEASE
that awoke him from sleep with associated
diaphoresis
DISEASE
. At[**Hospital1 2436**] EKG showed inferior ST-elevations new from prior inthat system from [**2133**]. He was subsequently transferred to [**Hospital1 18**]for management of his STEMI..In the cath lab he underwent a Right radial approach. Foundproximal RCA occlusion. Passed wire and baloon inflation withvagal response requireing 1 dose of atrompine and transient hearblock. Venous sheath placed but no transveous pacer placed. BP'shung around 100's and response to IVF. Placed 3 BMS in RCA fromproximal to distal. Large vessel. Did not have completeresolution of STE with some residual [**3-26**] CP that is steadilyimproviong. Has ASA and PLavix on board and integrillin x18hours. Will leave venous sheath in for access. Otherwise stable.Past Medical History:1. CARDIAC RISK FACTORS: -Diabetes Admission Date: [**2184-10-16**] Discharge Date: [**2184-10-18**]Date of Birth: [**2131-1-2**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4760**]Chief Complaint:Etoh withdrawalMajor Surgical or Invasive Procedure:noneHistory of Present Illness:53year-old male with a history of Etoh abuse w/h/o
seizures
DISEASE
w/withdrawal who presented w/acute etoh intoxication to the ED 1day PTA. His initial Etoh level was 429 w/last drink day 1 dayPTA. He drink 2 bottles of vodka daily. He was observedovernight in the ED and appeared to be stable until this AM whenhe became
hypertensive
DISEASE
and tachycardic..In the ED he was afebrile BP 162/103 HR 62 O2sat 97%RA. Hereceived Thiamine folate and Diazepam 5 mg IV x 1(once at 9AMand once at 10AM) per CIWA scale which was started this AM..ROS: The patient denies any
fevers chills
DISEASE
weight change
nausea vomiting abdominal pain diarrhea constipation
DISEASE
melena hematochezia chest pain shortness of breath
DISEASE
orthopnea PND
lower extremity oedema cough
DISEASE
urinaryfrequency
urgency dysuria lightheadedness
DISEASE
gait unsteadiness
focal weakness vision
DISEASE
changes
headache rash
DISEASE
or skin changes.Past Medical History:-Alcohol abuse h/o withdrawal c/b
seizures
DISEASE
-Hypertension-Hepatitis C-Seizure disorderSocial History:Smokes a few cigarettes a day x many years. Heavy alcoholhistory about 1pint vodka a day now. History IVDUcocaine/crack use Multiple unprotected female partners.Homeless living at shelter. Mainly around [**Hospital1 756**] Circle. PCPis [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] [**Hospital 2025**] healthcare for the homeless. Liveswith sister in [**Name (NI) 5110**] when sober. Works in trucking whensober. He was born in [**State 5111**] worked as a chef. He finishedHigh SchoolFamily History:Non-contributoryPhysical Exam:Vitals: T 99.4 : BP 170/110 : HR 80 : RR 17 : O2Sat: 97%
RA
DISEASE
GEN: anxiouse appearing well-nourished in obviouse distressHEENT: EOMI PERRL no
epistaxis
DISEASE
or
rhinorrhea
DISEASE
MMM OP ClearNECK: No JVD carotid pulses brisk no
bruits
DISEASE
no cervical
lymphadenopathy
DISEASE
trachea midlineCOR: RRR no M/G/R normal S1 S2 radial pulses Admission Date: [**2187-8-7**] Discharge Date: [**2187-8-9**]Date of Birth: [**2131-1-2**] Sex: MService: NEUROSURGERY
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 78**]Chief Complaint:FallMajor Surgical or Invasive Procedure:noneHistory of Present Illness:This is a 56 year old man who has been seen in the Ed onmultiple occasions for frequent falls while intoxicated. He fellfrom standing the night of admission and this was witnessed byfriends. [**Name (NI) **] was transferred to [**Hospital1 18**] for evaluation. CT headshowed bilateral SDH. He received Dilantin 1gm IV x1.Neurosurgery was consulted.Past Medical History:1. Alcoholism prior MICU admission for airway protection duringacute intoxication (w/ valium overdose).2. Hepatitis C.3.
Seizure disorder
DISEASE
.4. Status post
depressed skull fracture
DISEASE
in [**2162**].5. Status post right craniotomy.6. Status post C4
fracture
DISEASE
in [**2173**].7. Status post
delirium tremens
DISEASE
.8. H/o Aspiration
pneumonia
DISEASE
.9.
Hypertension
DISEASE
.10. Right ankle
fracture
DISEASE
.11. Right arm
thrombophlebitis
DISEASE
.Social History:He is homeless and currently staying with friends. [**Name (NI) **] reportsto parole services. He is not currently working. He has a 43year smoking history currently smokes Admission Date: [**2145-7-7**] Discharge Date: [**2145-7-20**]Date of Birth: [**2096-7-25**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 30**]Chief Complaint:
dyspnea
DISEASE
Major Surgical or Invasive Procedure:R IJ -intubation -History of Present Illness:48M with h/o severe
COPD
DISEASE
(on 2-5L home O2) presenting to OSHwith 2-3wk of increased SOB with
cough
DISEASE
productive ofyellow/white sputum though per his wife no clear
fevers
DISEASE
chest
pain
DISEASE
n/v abd
pain diarrhea rash joint pains
DISEASE
. His wife notespoor compliance with his fluid and dietary restriction andincreasing weight from Admission Date: [**2145-7-7**] Discharge Date: [**2145-7-20**]Date of Birth: [**2096-7-25**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 30**]Chief Complaint:
dyspnea
DISEASE
Major Surgical or Invasive Procedure:Right IJ catheterIntubation for mechanical ventilationRight PICC lineHistory of Present Illness:48 year-old gentleman with severe
COPD
DISEASE
(2-5L home O2)
CHF
DISEASE
andmultiple lengthy prior admissions. Initially presented to OSHwith 2-3 weeks increased SOB and
cough
DISEASE
productive ofyellow/whote sputem but signed out AMA. Admitted to [**Hospital1 18**] MICUon [**7-7**] with
COPD
DISEASE
flare and treated with solumedrol nebscefodoxine/azithromycin and diuretics. Called out from MICU butthen taken back to MICU due to increased
dyspnea
DISEASE
and
tachypnea
DISEASE
.Intubated and extubated on [**7-14**]. Was net negative 15L acrossMICU stays. Also received 7-day course of vanc/zosyn for HAP.At time of transfer patient was stable. Per ICU patient is stillvolume overloaded and needs further diuresis. Patient would beappropriate for transfer to LTAC bed after the weekend.On the floor pt was not in any acute distress lying in areclining position and requesting to go home tomorrow. Whenasked why he said Admission Date: [**2148-12-2**] Discharge Date: [**2148-12-11**]Date of Birth: [**2084-12-30**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2145**]Chief Complaint:
respiratory distress
DISEASE
Major Surgical or Invasive Procedure:BiPAPHistory of Present Illness:64 yo AA male with HIV/AIDS (VL: 570Admission Date: [**2145-9-6**] Discharge Date: [**2145-9-9**]Date of Birth: [**2096-7-25**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 3531**]Chief Complaint:
Shortness of breath
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Mr. [**Known lastname 5981**] is a 49M with
COPD
DISEASE
(FEV1Admission Date: [**2187-9-3**] Discharge Date: [**2187-9-6**]Date of Birth: [**2131-10-29**] Sex: MService: MEDICINE
Allergies
DISEASE
:Beta-Adrenergic Blocking Agents / ShellfishAttending:[**First Name3 (LF) 689**]Chief Complaint:CC:[**CC Contact Info 5995**]Major Surgical or Invasive Procedure:Upper endoscopyColonoscopyHistory of Present Illness:HPI: This is a 55 yo Male with a hx afib
HTN
DISEASE
who had BRBPRtonight then syncopized in the bathroom. Denies LOC or
trauma
DISEASE
tohis head. The patient denies
CP/Abd
DISEASE
Pain/dyspnea or othersymptoms. Weak x2days and 1 episode of loose stool yesterday.Does report
abdominal cramping
DISEASE
. No history of prior
GIB
DISEASE
. Neverhad colonscopy in past. No NSAID useAdmission Date: [**2182-6-18**] Discharge Date: [**2182-7-2**]Date of Birth: [**2113-10-31**] Sex: MService: [**Hospital Unit Name 196**]
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 2387**]Chief Complaint:Chest pressure x 4dMajor Surgical or Invasive Procedure:Left heart catheterization and taxus stentHistory of Present Illness:68 y/o male with a h/o CAD with a LAD stent placed in [**5-31**] whowas doing well at home s/p cath for approximately one week whenhe developed chest pain/pressure lasting four days before hecame to [**Hospital1 18**] ED. Pt's ECG was consistent with reinfarctionAdmission Date: [**2182-2-5**] Discharge Date: [**2182-2-6**]Date of Birth: Sex: MService: NeurosurgeryHISTORY OF PRESENT ILLNESS: Patient was an 84-year-old manwho had a fall at home after a bad
headache
DISEASE
with positive
loss of consciousness
DISEASE
. 911 was called and he was brought tothe Emergency Room awake and alert. Initial CAT scan of thehead did show a
small right subdural hematoma
DISEASE
as well as left
temporal contusions
DISEASE
with
ventricular blood
DISEASE
. He was scheduledfor a MRI of the brain when his mental status deteriorated.Repeat CAT scan of the head showed a larger
subdural hematoma
DISEASE
on the left side as well as increased
contusions
DISEASE
in the lefttemporal region and blood in the fourth ventricle which wasincreased.He was emergently taken to the OR for left craniotomy andevacuation of a
subdural hematoma
DISEASE
.PAST MEDICAL HISTORY:1.
Coronary artery disease
DISEASE
status post MI in [**2153**].2. CABG x4 in [**2169**].3. Non-insulin dependent-diabetes
mellitus
DISEASE
.4. GERD.5.
Cataracts
DISEASE
.6.
Glaucoma
DISEASE
.7.
Hypertension
DISEASE
.8.
Osteoarthritis
DISEASE
.9.
Prostate cancer
DISEASE
status post TURP in [**2170**].10. Status post colon resection for
adenoma
DISEASE
.MEDICATIONS AT TIME OF ADMISSION:1. Isosorbide.2. Lasix.3. Procardia.4. Naprosyn.5. Diazepam.6. Chlorpropamide.SOCIAL HISTORY: He was not a smoker. Did not drink alcohol.ALLERGIES: He has
allergies
DISEASE
to dye and shellfish.HOSPITAL COURSE: Postoperatively he remained intubated.His vital signs were stable. His left pupil was nonreactiveat 6 mm and the right was 2 mm and nonreactive. He had nocorneal reflexes no gag response or
cough
DISEASE
. He had bloodydrainage from the ventricular drain. He had a poorprognosis.On [**2182-2-6**] he had a cold caloric test which wasnegative had no response. He continued to be managed in theIntensive Care Unit. With discussion initially with his wifeand daughter and later with a nephew and after muchdiscussion the family opted to withdraw care.On [**2182-2-6**] at 3:20 p.m. the patient expired. [**Name6 (MD) 742**] [**Name8 (MD) **] M.D. [**MD Number(1) 743**]Dictated By:[**Last Name (NamePattern1) 5996**]MEDQUIST36D: [**2182-4-8**] 12:04T: [**2182-4-9**] 07:27JOB#: [**Job Number 5997**]Admission Date: [**2182-2-5**] Discharge Date: [**2182-2-6**]Date of Birth: Sex: MService: NeurosurgeryHISTORY OF PRESENT ILLNESS: Patient was an 84-year-old manwho had a fall at home after a bad
headache
DISEASE
with positive
loss of consciousness
DISEASE
. 911 was called and he was brought tothe Emergency Room awake and alert. Initial CAT scan of thehead did show a
small right subdural hematoma
DISEASE
as well as left
temporal contusions
DISEASE
with
ventricular blood
DISEASE
. He was scheduledfor a MRI of the brain when his mental status deteriorated.Repeat CAT scan of the head showed a larger
subdural hematoma
DISEASE
on the left side as well as increased
contusions
DISEASE
in the lefttemporal region and blood in the fourth ventricle which wasincreased.He was emergently taken to the OR for left craniotomy andevacuation of a
subdural hematoma
DISEASE
.PAST MEDICAL HISTORY:1.
Coronary artery disease
DISEASE
status post MI in [**2153**].2. CABG x4 in [**2169**].3. Non-insulin dependent-diabetes
mellitus
DISEASE
.4. GERD.5.
Cataracts
DISEASE
.6.
Glaucoma
DISEASE
.7.
Hypertension
DISEASE
.8.
Osteoarthritis
DISEASE
.9.
Prostate cancer
DISEASE
status post TURP in [**2170**].10. Status post colon resection for
adenoma
DISEASE
.MEDICATIONS AT TIME OF ADMISSION:1. Isosorbide.2. Lasix.3. Procardia.4. Naprosyn.5. Diazepam.6. Chlorpropamide.SOCIAL HISTORY: He was not a smoker. Did not drink alcohol.ALLERGIES: He has
allergies
DISEASE
to dye and shellfish.HOSPITAL COURSE: Postoperatively he remained intubated.His vital signs were stable. His left pupil was nonreactiveat 6 mm and the right was 2 mm and nonreactive. He had nocorneal reflexes no gag response or
cough
DISEASE
. He had bloodydrainage from the ventricular drain. He had a poorprognosis.On [**2182-2-6**] he had a cold caloric test which wasnegative had no response. He continued to be managed in theIntensive Care Unit. With discussion initially with his wifeand daughter and later with a nephew and after muchdiscussion the family opted to withdraw care.On [**2182-2-6**] at 3:20 p.m. the patient expired. [**Name6 (MD) 742**] [**Name8 (MD) **] M.D. [**MD Number(1) 743**]Dictated By:[**Last Name (NamePattern1) 5996**]MEDQUIST36D: [**2182-4-8**] 12:04T: [**2182-4-9**] 07:27JOB#: [**Job Number 5997**]Admission Date: [**2106-11-18**] Discharge Date: [**2106-11-27**]Date of Birth: [**2058-1-23**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1283**]Chief Complaint:
Syncope
DISEASE
Major Surgical or Invasive Procedure:[**2106-11-22**] Aortic Valve Replacement utilizing a 27mm CE PerimountPericardial Tissue ValveHistory of Present Illness:This is a 48 year old male who was admitted to outside hospitalafter
syncopal
DISEASE
episode. Noted to be in rapid
atrial fibrillation
DISEASE
at that time and converted back to a normal sinus rhythm withLopressor and intravenous Cardizem. Echocardiogram revealedbicuspid aortic valve with severe critical
aortic stenosis
DISEASE
. Theaortic valve area was estimated at 0.6cm2. His left ventricularejection fraction was 55-60%. Cardiac catheterization on [**11-17**] confirmed severe
aortic stenosis
DISEASE
. Coronary angiographyrevealed clean coronary arteries. Based on the above results hewas transferred to the [**Hospital1 18**] for cardiac surgical intervention.Past Medical History:
Aortic Stenosis
DISEASE
Childhood Heart Murmur History of
Atrial
Fibrillation
DISEASE
History of
Migraine Headaches Horseshoe Kidney
DISEASE
Social History:Denies tobacco and excessive ETOH. Married with children. Worksin construction. Currently lives with his wife.Family History:Uncle died suddenly at young age(before 55).Physical Exam:Vitals: BP 110/84 HR 71 RR 16 SAT 96% on room airGeneral: well developed male in no acute distressHEENT: oropharynx benign left
temporal ecchymosis
DISEASE
stitchesnoted below lower lipNeck: supple no JVDHeart: regular rate normal s1s2 4/6 systolic ejectiom murmurwhich radiated to carotid regionLungs: clear bilaterallyAbdomen: soft nontender normoactive bowel soundsExt: warm no
edema
DISEASE
varicosities noted on left legPulses: 2Admission Date: [**2135-7-15**] Discharge Date: [**2135-7-25**]Date of Birth: [**2096-2-16**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1070**]Chief Complaint:SOBMajor Surgical or Invasive Procedure:[**2135-7-17**] IVC Filter PlacedHistory of Present Illness:39 y/o M with PMHx of
HTN iritis
DISEASE
who presented to his PCP'soffice with a 2 days of worsening SOB and
dizziness
DISEASE
on standingafter going to the gym.Patient said on tuesday he noticed left calf Admission Date: [**2170-10-19**] Discharge Date: [**2170-10-27**]Date of Birth: [**2124-3-6**] Sex: MService: MEDICINE
Allergies
DISEASE
:CodeineAttending:[**Known firstname 30**]Chief Complaint:
Hemoptysis
DISEASE
Major Surgical or Invasive Procedure:Endotracheal Intubation for
Respiratory Arrest
DISEASE
secondary tosedationHistory of Present Illness:46M h/o alcohol abuse HCV [**3-9**] [**2141**] blood transfusion GERDadmitted with self-reported
hemoptysis
DISEASE
and CP also found to bealcohol intoxicated. Pt had attended baseball game at which hedrank about 12 beers. Afterwards while walking home ptsuddenly coughed up several tablespoonfuls of blood (per pt'sreport to NF he coughed one T of bright red blood). At thattime pt also developed sudden onset L sided CP initiated andaggravated by breathing accompanied by SOB. Pt later reportedthat this
pain
DISEASE
had changed to the R side. Pt noted no otheradditional symptoms. Pt then called EMS and was brought to ED.. ED:# VS: T 98.1 HR 100 BP 120/76 RR 14 SaO2 96/RA# Meds: ASA 325 nitroglycerin SL hydralazine metoprolol(
AFib
DISEASE
RVR) levofloxacin (empiric Rx for PNA). Multiple
pain
DISEASE
medications (acetaminophen ibuprofen morphine Percocethydromorphone). Diazepam per
CIWA
DISEASE
.# Studies: CXR demonstrated ground glass
opacities
DISEASE
# Clinical course:
Afib
DISEASE
Admission Date: [**2169-4-5**] Discharge Date: [**2169-4-16**]Date of Birth: [**2125-10-11**] Sex: FService: MEDICINE
Allergies
DISEASE
:E-Mycin / Penicillins / CodeineAttending:[**First Name3 (LF) 689**]Chief Complaint:
Dyspnea
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:43F H/O
IPF
DISEASE
COPD/Asthma (Multiple Intubations) CurrentSmoking Schizoaffective Disorder/Depression with URI symptomsand
dyspnea
DISEASE
. Patient was well until about one week ago when shedeveloped
rhinorrhea productive cough
DISEASE
of yellow sputum
chills
DISEASE
fevers
DISEASE
mild right ear pain fatigue and then increased
dyspnea
DISEASE
PND orthopnea
DISEASE
and decreased exercise tolerance. There was no
rash headache sore throat nausea vomiting diarrhea
DISEASE
constipation chest pain
DISEASE
leg
pain
DISEASE
but has chronic mild
swelling
DISEASE
. She saw her PCP and had mild improvement withnebulizers. Her symptoms then worsened and she called EMS.ED Course: Afebrile. OS85%RA. Peak flow at 250 (baseline of350). CXR showing
perihilar haziness
DISEASE
with asymmetric hilarfullness and no definite infiltrate. Started on LevofloxacinNebs and admitted to Medicine.Past Medical History:1.
IPF
DISEASE
: DIP transthoracic lung bx ([**2166**]) negative2. COPD/Asthma: Spirometry ([**5-/2164**]) FVC 2.48 (67%) FEV1 1.96(68%) FEV1/FVC 101% DLCO ([**4-/2163**]) 51% Lung vol ([**4-/2163**]): TLC 64%FRC 48% RV 49% ERV 47% multiple admissions intubation x 1[**2163**]3. Current Smoking4.
Schizoaffective Disorder
DISEASE
(VH/AH/Paranoia/Olfactory
Hallucinations
DISEASE
)5.
Depression
DISEASE
6. H/O Heavy ETOH Use and DTs7. TLE (Most Recent Sz five years ago)8. H/O VRE/MRSA9. PPD Positive S/P INH10. H/O
Meningitis
DISEASE
11. S/P Ex Lap12.
Hyperlipidemia
DISEASE
13. DMSocial History:She lives alone and is a jewlery maker. She currently smokes andhas 30 pack-years. She is detemited to quit smoking today. Sheused marijuana cocaine and LSD as a teenager but has not useddrugs since then. She rarely drinks ETOH.Family History:No lung or known
autoimmune disease
DISEASE
(such as
SLE
DISEASE
Rh orSjogrens). Her father and mother died from
MIs
DISEASE
at ages 55 and63 resp. Her siblings had
MIs
DISEASE
in their 40s.Physical Exam:T100.3 HR115 BP144/69 OS95%2L.GEN - NAD. SPEAKING IN FULL SENTENCES. EATING.HEENT - MMM. CLEAR OP. ANICTERIC.RESP - B/L EXP WHEEZES WITH POOR AIR MOVEMENT. Improving withpeak flows Admission Date: [**2200-12-13**] Discharge Date: [**2200-12-22**]Date of Birth: [**2141-8-5**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Last Name (NamePattern1) 1136**]Chief Complaint:
Shortness of breath
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:Mr. [**Known lastname 6013**] is a 59 year-old male with
schizophrenia dementia
DISEASE
COPD
DISEASE
unspecified
CHF seizure disorder
DISEASE
current smoker andrecent
pneumonia
DISEASE
treated with levofloxacin ([**9-17**]) admitted from[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Nursing Home and Rehab ([**Name8 (MD) 4134**] RNAdmission Date: [**2151-9-21**] Discharge Date: [**2151-9-24**]Date of Birth: [**2084-12-30**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2167**]Chief Complaint:nausea/emesis x 2 daysMajor Surgical or Invasive Procedure:noneHistory of Present Illness:This is a 66 yo M w/h/o HIV(last CD4 307 [**2151-9-10**] VL 187[**2151-9-15**])
HTN
DISEASE
and severe
COPD
DISEASE
on 3L oxygen at home whopresents w/nausea and
emesis
DISEASE
x 2 days. He notes that he had beenfeeling generally well but with
constipation
DISEASE
when he had suddenonset of
nausea
DISEASE
and
emesis
DISEASE
2 nights ago. He does not recall whathe was doing. Since then he has been tolerating some food buthas had several episodes of NBNB
emesis
DISEASE
. He notes that he hasnot taken any of his medications x 2 days due to the
nausea
DISEASE
. Healso notes that a few days PTA he took one dose of his newantiretroviral regimen- unsure which pill- and had
nausea
DISEASE
. Hesubsequently stopped that regimen and reverted back to his oldregimen. He denies subjective fever/chills. Notes mild diffuse
nonfocal abdominal pain
DISEASE
which he feels is caused by the
nausea
DISEASE
and is worse w/eating. He feels that his
nausea
DISEASE
and abdominal
pain
DISEASE
is c/w severe
constipation
DISEASE
Admission Date: [**2170-7-18**] Discharge Date: [**2170-9-1**]Date of Birth: [**2109-1-7**] Sex: MService: MEDICINE
Allergies
DISEASE
:Pollen/HayfeverAttending:[**First Name3 (LF) 6021**]Chief Complaint:
Fever
DISEASE
Major Surgical or Invasive Procedure:ThoracentesisHistory of Present Illness:HPI: Patient is a 61 y/o male with
cutaneous squamous cell
carcinoma
DISEASE
metastatic to regional lymph nodes currently receivingXRT with Cisplatin who p/w malaise and febrile
neutrophenia
DISEASE
. Ptnoted malaise for the last couple of days prior to admissionwith temp elevated to 101.5 at home. Sx included sore throatAdmission Date: [**2123-6-22**] Discharge Date: [**2123-6-25**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:
sepsis
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:[**Age over 90 **] yo M with
HTN
DISEASE
s/p L [**Hospital 6024**] hospital course [**Date range (1) 6025**] fornon-healing
infected foot
DISEASE
([**1-13**] limb
ischemia
DISEASE
per non-invasivesnot on record in OMR) complicated by
VRE infection
DISEASE
requiringintraoperative debridement and AKA. Patient was discharged to[**Hospital3 2732**] and Retirement Home in [**Location (un) 55**] wherewas in USOH until [**2123-6-21**] when noted
chills lethargy
DISEASE
low-grade feverAdmission Date: [**2122-5-11**] Discharge Date: [**2122-5-17**]Date of Birth: [**2038-11-13**] Sex: MService: MEDICINE
Allergies
DISEASE
:Serevent Diskus / Theraflu Multi SymptomAttending:[**First Name3 (LF) 832**]Chief Complaint:
hematuria weakness hypotension
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:83-year old Russian-speaking male with a pastmedical history of
IDDM asthma AFib
DISEASE
on coumadin CAD s/p CABGin [**2105**]
diabetic ulcers chronic
DISEASE
venous stasis
DISEASE
dematitis/severe
lower extremity edema
DISEASE
follwoed by vascular service presentingwith
hematuria
DISEASE
shaking in his R arm and
hypotension
DISEASE
andtachycarida noted in the ED. History was obtained from son andwife who speak English and are patient's primary caretakers.[**Name (NI) **] has been declining since around [**Month (only) 1096**]Admission Date: [**2122-9-3**] Discharge Date: [**2122-9-21**]Date of Birth: [**2038-11-13**] Sex: MService: MEDICINE
Allergies
DISEASE
:Serevent Diskus / Theraflu Multi SymptomAttending:[**Doctor Last Name 1857**]Chief Complaint:Difficulty urinating urinary retension and
edema
DISEASE
Major Surgical or Invasive Procedure:Right heart catheterization [**2122-9-14**]Peripherally inserted central catheter insertion (PICC) [**2122-9-11**]History of Present Illness:This is an 83 year-old Russian-speaking man with diastolic heartfailure CKD DM on insulin
asthma atrial fibrillation
DISEASE
(onCoumadin) CAD (s/p CABG) h/o
colon cancer
DISEASE
newly diagnosed
breast cancer
DISEASE
(s/p biopsy 2 weeks ago) presenting with
abdominal distention
DISEASE
decreased urine output for the past twoweeks with
urinary retention
DISEASE
for the past two days.His wife noticed increasing
edema
DISEASE
and abdominal girthapproximately 1 month ago. He saw his outpatient cardiologistwho increased his Torsemide dose from 100 to 150 mg PO daily.Approximately 2 weeks ago his wife again noticed increasingabdominal girth and firmness as well associated with decreasingurine output. His cardiologist again increased his Torsemidedose to 200 mg PO daily on week ago. His
edema
DISEASE
and decreasedurine output continued to progress and he began to developscrotal
edema
DISEASE
. Two days prior to admission he was prescribedmetolazone 5 mg to be taken prior to dosing Torsemide. Howeverhe did not receive this medication. At this point he had urinaryretention and his wife brought him to the emergency department.Review of his medications from OMR revealed that he had beenprescribed Tamsulosin for BPH but he was not taking thismedication.In the ED initial VS T 97.5 HR 62 BP 99/49 RR 20 SaO2 96% on
RA
DISEASE
. His creatinine was 2.6 which was an increase above hisbaseline of 1.5-2. A Foley was placed Admission Date: [**2142-2-8**] Discharge Date: [**2142-2-9**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 398**]Chief Complaint:
Fatigue
DISEASE
Major Surgical or Invasive Procedure:Tranfusion of 2 units of packed red blood cellsHistory of Present Illness:88 yo M PMH of pancreatic CA no recent tx in clinic forsurvaillence CT scan (which showed no change) mentioned that hewas tired to his oncologist hct was 18.8 down from 28 in[**Month (only) 359**] sent to ED for eval.In the ED vitals on presentation were
T 97.7
DISEASE
BP 153/65 HR 70 RR24 97%RA. On exam he had no stool in rectal vault but mucouswas guaiac (Admission Date: [**2168-10-20**] Discharge Date: [**2168-10-25**]Date of Birth: [**2094-10-20**] Sex: MService: MEDICINE
Allergies
DISEASE
:Demerol / Ativan / Librium / ValiumAttending:[**First Name3 (LF) 5893**]Chief Complaint:Bilateral lower extremity
swelling
DISEASE
and
pain
DISEASE
Major Surgical or Invasive Procedure:IntubationHistory of Present Illness:Mr. [**Known lastname **] is a 73 yo male with CAD s/p CABG x4V in [**2154**]
HTN
DISEASE
HL A. fib on coumadin type 2 DM with
chronic venous stasis
DISEASE
and recurrent LLE cellulitis discharged from [**Hospital1 18**]-[**Location (un) 620**] in[**6-16**] for MRSA cellutis now presenting with increase rightlower extremity warmth
swelling redness
DISEASE
. He reported having atemperature to 102.4 earlier in the morning. Per wife patientdenied
shortness of breath cough chest pain diarrhea
DISEASE
abdominal pain dysuria
DISEASE
..On arrival to the ED patient's vitals were T 98.7 HR 103 BP74/55 RR 28 O2 sat 89-93% on
RA
DISEASE
. In the ED BP fell to 64/47. He was given 5L IVF but remained
hypotensive
DISEASE
so was started onLevophed. He was given Vancomycin and Zosyn to cover
cellulitis
DISEASE
. He got a CTA which showed no PE but showedbilateral pneumoniaAdmission Date: [**2111-7-18**] Discharge Date: [**2111-7-25**]Date of Birth: [**2036-7-23**] Sex: MService: CSUHISTORY OF PRESENT ILLNESS: This is a 75-year-old male witha history of
hypertension diabetes
DISEASE
and history of
syncope
DISEASE
in[**2100**] and severe
aortic stenosis
DISEASE
. He presented with
lightheadedness
DISEASE
for less than approximately one day. Thepatient had cardiac catheterization on [**2111-7-16**] to evaluateaortic valve which showed that the valve diameter was 0.68cm sq. The patient was to be evaluated for possible valvularsurgery in two weeks at [**Hospital6 1708**] but thepatient has not seen a surgeon since the catheterization. Thepatient has baseline
dyspnea
DISEASE
on exertion and the patientpresented with
lightheadedness
DISEASE
but no
loss of consciousness
DISEASE
.The patient denied
chest pain
DISEASE
and
shortness of breath
DISEASE
atrest
headaches palpitations
DISEASE
or
diaphoresis
DISEASE
. The patientalso denied
fever chills cough nausea vomiting
DISEASE
brightred blood per
rectum melena
DISEASE
or
hematemesis
DISEASE
.PAST MEDICAL HISTORY: History of
hypertension
DISEASE
hypercholesterolemia diabetes aortic stenosis
DISEASE
increasing
homocystinemia
DISEASE
history of
syncope
DISEASE
in [**2100**]
hyperthyroidism
DISEASE
induced
atrial fibrillation
DISEASE
and benign
prostatic hypertrophy
DISEASE
.ALLERGIES: No known drug allergies.MEDICATIONS:1. Aspirin 81 mg p.o. q day.2. Lipitor 10 mg p.o. q day.3. Glucophage 500 mg p.o. q a.m. and 1000 mg p.o. q p.m.4. Glyburide 10 mg p.o. q a.m. and 5 mg p.o. q p.m.5. Actos 30 mg p.o. q day.6. Folate 2 mg p.o. q h.s. and 1 mg p.o. q a.m.7. Multivitamin.8. Cardura 4 mg p.o. q h.s.FAMILY HISTORY: The patient has a brother with a myocardial
infarction
DISEASE
who underwent coronary artery bypass grafting.SOCIAL HISTORY: The patient is a cytologist. The patient hada distant tobacco history rarely drinks alcohol and liveswith his wife.PHYSICAL EXAMINATION: On arrival the patient's temperaturewas 97.9 pulse 58 blood pressure 148/59 respiratory rate18 100 percent saturation on room air. The patient generallyis an elderly gentleman in no apparent distress. Pupilsequal round and reactive to light.
Extraocular movements
DISEASE
intact. The patient has no
jugular venous distension
DISEASE
. Theneck is supple without
bruits
DISEASE
. The patient's heartexamination was regular rate and rhythm with apical murmurand
systolic like ejection murmur
DISEASE
. The patient's chest wasclear to auscultation bilaterally. The patient's abdomen wassoft nontender nondistended with positive bowel sounds. Thepatient's extremities had positive
edema
DISEASE
bilaterally.Neurologically the patient is alert and oriented with a fiveout of five strength throughout. The patient's skin had nolesions or rashes.LABORATORY DATA: On admission sodium 139 potassium 4.6chloride 102 bicarbonate 29 BUN 19 creatinine 0.9 glucose185. The patient's white blood cell count was 3.8 hematocrit32.7 platelets 148. The patient's urinalysis was negative.The patient had an echocardiogram in [**3-/2111**] that showed anejection fraction of greater than 55 percent with mildlydilated aortic root mild
aortic regurgitation
DISEASE
and mild
mitral regurgitation
DISEASE
. The patient had a cardiaccatheterization on [**2111-7-16**] which showed normal coronariessevere
aortic stenosis
DISEASE
mild
mitral regurgitation
DISEASE
mild
pulmonary hypertension
DISEASE
and a valvular area of 0.68 cm sq. Thepatient's electrocardiogram showed normal axis prolonged PRwithout any drop beats and no ST changes from priorelectrocardiogram.HOSPITAL COURSE: The patient was admitted to the Cardiologyservice under the care of Dr. [**Known lastname **]. The CardiothoracicSurgery service was consulted for evaluation of aortic valve.The patient was continued on his home regimen for
diabetes
DISEASE
and blood pressure was well controlled. The patient was seenby Cardiac Surgery and was evaluated to have repair of thesevere
aortic stenosis
DISEASE
. The patient underwent aortic valvereplacement with a 23 mm pericardial valve. The patienttolerated the procedure without any difficulties and was sentto the Cardiac Surgery Recovery Unit. Please see the dictatedOperative Note for details.On postoperative day one the patient was extubated and wasalso off inotropes. The patient remained in sinus rhythm withgood blood pressure. He was positive for approximately sevenliters since the operation. The patient's saturation was 93percent on three liters. He was advanced to a cardiac diet.He remained afebrile. BUN and creatinine were 15 and 0.6. Hereceived an insulin drip which was weaned. The patientcontinued to be on the vancomycin perioperatively. Thepatient was started on metoprolol and Lasix. The patient wasseen by Dr. [**Known lastname **] who felt that the patient had a slow sinusrate and atrioventricular conduction. The patient was seen bythe EP service who felt that there was no current indicationfor pacing with high output and felt that theatrioventricular conduction was good and there was no need tochange the pacer.On postoperative day two the patient was transferred to thefloor. He remained afebrile with stable vital signs. Thepatient's hematocrit was 28.2 and creatinine was 0.8. Thepatient's wires were removed. The patient was continued onLasix. The Lopressor was increased to 25 mg b.i.d.On postoperative day three the patient complained of some
left shoulder pain
DISEASE
. Otherwise he was doing well. The patienthad a rate of 100 and pressure of 108/20 with saturation of95 percent on two liters. The patient was continued onintravenous Lasix and metoprolol. The patient was put on
pain
DISEASE
medications for the left shoulder
pain
DISEASE
and
glaucoma
DISEASE
medication.On postoperative day four the patient's heart rate was inthe 90s with good pressure hematocrit of 24.7 and creatinineof 0.7. The patient was transfused one unit of packed redblood cells for the low hematocrit.On postoperative day five the patient had no eventsovernight. The patient had a temperature of 100. Otherwisehe had a good heart rate and blood pressure. The patient'sLasix was changed to p.o. and he was continued on metoprolol.The patient's hematocrit was 27.4 and potassium was 3.8which was repleted. Creatinine was 0.7. The patient wascleared by Physical Therapy and was discharged home.DISCHARGE DIAGNOSES: Aortic stenosis status post aorticvalve replacement
diabetes hyperlipidemia
DISEASE
high homocystinelevel
hyperthyroidism
DISEASE
appendectomy and hydrocele repair.DISCHARGE MEDICATIONS:1. Iron 150 mg p.o. q d.2. K-Dur 20 mEq for six days.3. Lasix 20 mg for six days.4. Colace 100 mg p.o. b.i.d.5. Aspirin 325 mg p.o. q day.6. Lipitor 10 mg p.o. q day.7. Zantac 150 mg p.o. q day.8. Cardura 4 mg p.o. q day.9. Percocet 1-2 tablets p.o. q 4-6 hours p.r.n.
pain
DISEASE
.10. Folic acid 2 mg p.o. b.i.d.11. Glyburide 10 mg p.o. q a.m. and 5 mg p.o. q p.m.12. Metformin 500 mg p.o. q a.m. and 1000 mg p.o. q p.m.13. Actos 30 mg p.o. q day.14. Metoprolol 25 mg p.o. b.i.d.15. Motrin 400 mg p.o. t.i.d. p.r.n.16. Timolol 0.5 percent one drop to the eyes q day.FOLLOW UP: Please follow-up with Dr. [**Last Name (STitle) 6051**] in one week.Please have hematocrit checked at that time. Please follow-upwith Dr. [**First Name8 (NamePattern2) **] [**Known lastname **] in two weeks. Please follow-up with[**Name6 (MD) **] [**Name8 (MD) **] M.D. in four weeks.DISPOSITION: Home with VNA.CONDITION ON DISCHARGE: Good. [**Name6 (MD) **] [**Name8 (MD) **] M.D. [**MD Number(2) 5897**]Dictated By:[**Doctor Last Name 6052**]
MEDQUIST36D: [**2111-7-25**] 12:26:42T: [**2111-7-25**] 13:11:01Job#: [**Job Number 6053**]Admission Date: [**2136-3-14**] Discharge Date: [**2136-3-15**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:transferred from nursing home for
respiratory failure
DISEASE
and
hypotension
DISEASE
Major Surgical or Invasive Procedure:IntubationHistory of Present Illness:Mr. [**Known lastname 6054**] is a [**Age over 90 **] yo man who was formerly DNR/DNI and Admission Date: [**2165-10-6**] Discharge Date: [**2165-10-11**]Date of Birth: [**2095-10-22**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 106**]Chief Complaint:
Dyspnea
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:Mr. [**Known lastname **] is a 69 year old man with severe
CHF
DISEASE
(EF Admission Date: [**2166-12-18**] Discharge Date: [**2166-12-21**]Date of Birth: [**2095-10-22**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4654**]Chief Complaint:
DKA weakness
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:71yoM with a history of DMII (on home Metformin) dilated
cardiomyopathy
DISEASE
(unclear etiology) EFAdmission Date: [**2150-2-25**] Discharge Date: [**2150-3-1**]Date of Birth: [**2086-12-19**] Sex: MService: NEUROSURGERY
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 1835**]Chief Complaint:left sided brain lesionMajor Surgical or Invasive Procedure:[**2-25**] Left Craniotomy for mass resectionHistory of Present Illness:[**Known firstname **] [**Known lastname 1852**] is a 62-year-old left-handed man who is here for afollow up of his left sphenoid meningioma. I last saw him on[**2149-11-17**] and his head CT showed growth of the left sphenoid
meningioma
DISEASE
. He is
seizure
DISEASE
free. Today he is here with hiswifeand daughter. [**Name (NI) **] does not have
headache nausea vomiting
DISEASE
urinary incontinence
DISEASE
or fall.His neurological problem began on [**2142-6-22**] when he becameconfused and disoriented in a hotel bathroom. At that time hewas visiting his daughter for a wedding. His wife found himslumped over in the bath tube. According to her his eyeslookedfunny. He could not stand up. His verbal output did not makesense. He was brought to [**Doctor First Name 1853**] Hospital in PlacentiaCA. He woke up 7 to 8 hours later in the emergency room. Hefelt very tired after the event. He was hospitalized from[**2142-6-22**] to [**2142-6-25**]. He had a cardiac pacemaker placement dueto irregular heart rate and
bradycardia
DISEASE
. He also had a head MRIthat showed a less than 1 cm diameter sphenoid meningioma.Past Medical History:
Cardiac arrhythmia
DISEASE
as noted above has apacemaker in place
prostate cancer
DISEASE
with prostatectomy and
hypertension
DISEASE
.Social History:Lives with his wife. Retired works parttimedriving a school bus.Family History:NCPhysical Exam:Temperature is 97.8 F. His blood pressureis 150/92. Pulse is 80. Respiration is 16. His skinhas full turgor. HEENT is unremarkable. Neck is supple.Cardiac examination reveals regular rate and rhythms. His lungsare clear. His abdomen is soft with good bowel sounds. Hisextremities do not show
clubbing cyanosis
DISEASE
or
edema
DISEASE
.Neurological Examination: His Karnofsky Performance Score is100. He is awake alert and oriented times 3. There Hislanguage is fluent with good comprehension. His recent recallisintact. Cranial Nerve Examination: His pupils are equal andreactive to light 4 mm to 2 mm bilaterally. Extraocularmovements are full. There is no
nystagmus
DISEASE
. Visual fields arefull to confrontation. Funduscopic examination reveals sharpdisks margins bilaterally. His face is symmetric. Facialsensation is intact bilaterally. His hearing is intactbilaterally. His tongue is midline. Palate goes up in themidline. Sternocleidomastoids and upper trapezius are strong.Motor Examination: He does not have a drift. His musclestrengths are [**5-16**] at all muscle groups. His muscle tone isnormal. His reflexes are 0 in upper and lower extremitiesbilaterally. His ankle
jerks
DISEASE
are absent. His toes aredown going. Sensory examination is intact to touch andproprioception. Coordination examination does not revealdysmetria. His gait is normal. He can do tandem. He does nothave a
Romberg
DISEASE
.PHYSICAL
EXAM
DISEASE
UPON DISCHARGE:non focalincision c/d/i dissolvable suturesPertinent Results:[**2-25**] CT Head: IMPRESSION:1. Likely
meningioma
DISEASE
along the greater [**Doctor First Name 362**] of the left sphenoidbonemeasuring 18 mm in diameter unchanged since the most recentstudy of [**11/2149**] with reactive bony changes as above.2. Bifrontal cortical atrophy which has progressed slightlyover the series of studies since the earliest studies of [**2142**].[**2-25**] CT Head: IMPRESSION:Expected post-operative changes with the left frontal craniotomyincludingsubcutaneous air and soft tissue
swelling
DISEASE
moderate
pneumocephalus
DISEASE
overlying predominantly the bilateral frontallobes and foci of
hemorrhage
DISEASE
in the surgical bed. No evidenceof residual
tumor
DISEASE
on this non contrast CT.[**2-26**] CXR: FINDINGS: The lung volumes are rather low. There ismoderate
cardiomegaly
DISEASE
without evidence of overt
pulmonary edema
DISEASE
.No areas of
atelectasis
DISEASE
or
pneumonia
DISEASE
. Right pectoral pacemakerin situ with correct lead placement.[**2-28**] Head CT /c contrast: IMPRESSION: Status post left frontalcraniotomy changes with improvement of
pneumocephalus
DISEASE
and stable3 mm left to right midline shiftAdmission Date: [**2152-2-15**] Discharge Date: [**2152-3-2**]Date of Birth: [**2084-12-30**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1070**]Chief Complaint:
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:Endotracheal IntubationArterial line placementInternal Jugular line placementHistory of Present Illness:Mr. [**Known lastname 2150**] is a 67M with HIV (Cd4 183 VL 96 copies/mL) and endstage
COPD
DISEASE
on 3-4L home O2 with a FEV1 of 0.5 who presented tothe emergency room on [**2152-2-15**] with increased
shortness of
breath
DISEASE
. Three days prior to presentation he developed nasal
congestion
DISEASE
and
rhinorrhea
DISEASE
which made it difficult for him to usehis supplemental oxygen at home. He had subjective
fevers
DISEASE
and
chills
DISEASE
but did not check his temperature. He had minimal
cough
DISEASE
productive of dark yellow sputum. He was feeling more short ofbreath despite increasing oxygen use. He was concerned about
pneumonia
DISEASE
and presented to the emergency room..In the emergency room his initial vitals were T: 98.1 HR: 86 RR:107/72 RR: 22 O2: 100% on
RA
DISEASE
. He had a chest xray which showedsignificant hyperinflation but no acute cardiopulmonary process.He received levofloxacin 750 mg IV x 1 duonebs solumedrol 125mg IV x 1 and aspirin 81 mg. He was initially admitted to thefloor..While on the floor he was started on azithromycin solumedrol125 mg IV TID albuterol and ipratropium nebulizers. He did wellon hospital day 1 but overnight his
shortness of breath
DISEASE
worsened. He had a repeat CXR which was similar to priors. Hehad an ABG on a non-rebreather which was 7.37/57/207/34. He hadincreased work of breathing and asked to be placed on Admission Date: [**2176-11-21**] Discharge Date: [**2176-11-26**]Date of Birth: Sex: MService:HISTORY OF PRESENT ILLNESS: The patient is a 43-year-oldmale with a past medical history of
diabetes hypertension
DISEASE
and deep
venous thrombosis
DISEASE
presenting with a
fever
DISEASE
and lowerextremity
pain
DISEASE
times one day.In the Emergency Department the patient was noted to have a
fever
DISEASE
and
hypotension
DISEASE
. He received 6 liters of intravenousfluids Ancef and Unasyn and was transferred to the MedicalIntensive Care Unit.PAST MEDICAL HISTORY:1. Type 2
diabetes mellitus
DISEASE
.2. Hypertension.3. Bilateral deep
venous thrombosis
DISEASE
.4. High cholesterol.5. Anal fissure.6. Thalassemia.MEDICATIONS ON ADMISSION: Actos Glucophage atenololaspirin and Lipitor.ALLERGIES: ERYTHROMYCIN.SOCIAL HISTORY: No alcohol. No tobacco. No drug use.FAMILY HISTORY: Mother with
diabetes
DISEASE
.PHYSICAL EXAMINATION ON PRESENTATION: On physicalexamination the patient had a temperature of 103.5 hisheart rate was 112 his blood pressure was 109/50 hisrespiratory rate was 20 and his oxygen saturation was 100%on 2 liters. In general he was alert and oriented timesthree. In no acute distress. Head eyes ears nose andthroat examination revealed the sclerae were anicteric. Theoropharynx was clear. No
neck stiffness
DISEASE
. Cardiovascularexamination revealed a regular rate and rhythm. Normal firstheart sounds and second heart sounds. No murmurs. The lungswere clear to auscultation bilaterally. The abdomen wassoft nontender and nondistended. Positive bowel sounds.Extremities revealed right lower extremity venous changes.
Pain
DISEASE
the medial thigh to the calf. No
rash
DISEASE
. Neurologicexamination revealed
cranial nerves II
DISEASE
through XII wereintact. Sensation and strength were [**6-10**]. Distal pulses were2Admission Date: [**2179-8-9**] Discharge Date: [**2179-8-17**]Date of Birth: [**2133-5-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:E-MycinAttending:[**First Name3 (LF) 3507**]Chief Complaint:RLE Cellulitis/Code
Sepsis
DISEASE
Major Surgical or Invasive Procedure:Central Line PlacementHistory of Present Illness:46 yo M with
HTN DM2
DISEASE
who presents to the ED with 1 day ofright lower extremity warmness. Pt and wife say that yesterdayhe was feeling fatigued and Admission Date: [**2173-12-31**] Discharge Date: [**2174-1-8**]Service:HISTORY OF PRESENT ILLNESS: This is an 85-year-old womanwith history of
hypertension
DISEASE
who was admitted to an outsidehospital prior to being admitted to [**Hospital1 190**] on [**12-31**]. At the outside hospital the patienthad investigation for two month history of
abdominal pain
DISEASE
which showed mainly epigastric. This work-up includedabdominal CT which showed thickened duodenal valve 2 cmadrenal mass question of
colon lesion
DISEASE
consistent with
intermittent intestinal obstruction
DISEASE
. Her CEA at the outsidehospital was 41. She was admitted to [**Hospital1 190**] on [**12-31**] with worsening of the abdominal
epigastric pain nausea vomiting
DISEASE
for two days. In thehospital the patient had work-up which included CT angiogramdue to abnormal EKG initially which revealed pulmonary
embolism
DISEASE
and patient had been started on Heparin. Herinitial EKG revealed T wave inversion at V2 and V6 plus ST
depression
DISEASE
so she was also admitted for rule out MI. CT alsorevealed
dilated common bile duct
DISEASE
up to 18 mm. Herhematocrit on admission was 29.0 and drifted to 22.5 on[**1-1**]. She had two episodes of
coffee ground emesis
DISEASE
on[**1-1**] became
hypotensive
DISEASE
and bradycardic and acute EGD wasperformed which revealed grade 3
esophagitis
DISEASE
in the lowerthird
ulcer
DISEASE
in the stomach body and antrum blood in thestomach and anterior vault. There was large
oozing
DISEASE
clot inthe duodenal bulb. Hemostasis was achieved with Epinephrineinjection. Anticoagulation was discontinued and patient wasstarted on Protonix drip and had been transferred to medicalIntensive Care Unit due to
hypotension
DISEASE
and
active bleeding
DISEASE
.The same day she had IVC filter placed which was done on[**1-2**]. The patient received two units of FFP followed by 6units of packed red blood cells. On [**1-2**] the patient wastransferred back to the medicine floor and on [**1-3**] she had asecond EGD done due to hematocrit of 33.6 which drifted to32.2. EGD at that time revealed
esophagitis ulcers
DISEASE
in theantrum which were injected with Epinephrine and alsoposterior bulb injection and thermal therapy a large
inferior posterior duodenal ulcer
DISEASE
with
oozing
DISEASE
refractory toinjection. For this reason the patient underwent angiographyrevealing the source of
bleeding
DISEASE
and underwent
duodenal
gastric artery embolization
DISEASE
. She was then transferred withadditional two units packed red blood cells. Her hematocritafter transfusion went to 38.5 on [**1-4**].Other studies during the hospital course included chest x-raywhich revealed widened mediastinum secondary to tortuous and
dilated thoracic aorta
DISEASE
and
bibasilar atelectasis
DISEASE
. CTArevealed moderate intra and
extrahepatic ductal
DISEASE
dilatationleft
pulmonary artery embolism
DISEASE
and left adrenal mass.Ultrasound of the lower extremities revealed no
DVT
DISEASE
KUBrevealed no obstruction and chest x-ray on [**1-5**] revealedbilateral small
pleural effusion
DISEASE
with consolidation of thelower lobe presenting either
atelectasis
DISEASE
or
infection
DISEASE
. Shewas transferred to general medicine floor on [**1-5**].PAST MEDICAL HISTORY: Includes
hypertension non-insulin
DISEASE
dependent
diabetes mellitus coronary artery disease
DISEASE
statuspost MI status post CCY.MEDICATIONS: At home Zocor Aspirin Atenolol IsosorbideMeclizine Pravachol Imdur. On transfer Protonix 40 mg[**Hospital1 **] Lopressor 50 mg [**Hospital1 **] Accolate 20 mg [**Hospital1 **] Pravachol 20 mgq d Tylenol 650 mg qid Nephrocaps Captopril 12.5 mg tidMagnesium Oxide 400 mg [**Hospital1 **] Ambien prn.ALLERGIES: No known
drug allergies
DISEASE
.SOCIAL HISTORY: The patient denies smoking or alcohol.FAMILY HISTORY: Significant for father who died from
esophageal cancer
DISEASE
and mother from
stroke
DISEASE
.PHYSICAL EXAMINATION: On admission to medicine temperature98.0 heart rate 72 respiratory rate 20 blood pressure164/78 98% on one liter. Patient in no acute distresspale. HEENT: Revealed no
icterus
DISEASE
pupils are equal roundand reactive to light and accommodation oropharynx clearmucus membranes are dry. Neck no JVP. Cardiac S1 and S2regular rate and rhythm no murmur. Lungs CTA. Abdomensoft nontender non distended with
positive bowel sounds
DISEASE
.Extremities with no
edema
DISEASE
and normal peripheral pulsation.HOSPITAL COURSE: This is an 85-year-old woman with historyof
hypertension non-insulin
DISEASE
dependent
diabetes mellitus
DISEASE
coronary artery disease
DISEASE
now admitted with a two monthhistory of
epigastric pain
DISEASE
. She was found to have peptic
ulcer disease
DISEASE
with
massive GI bleeding
DISEASE
requiring twice EGDinjection with Epinephrine embolization of gastroduodenalartery. Her detailed hospital course is described in theHPI. After transfer to medicine service she remained stableand her hematocrit remained stable as well.LABORATORY DATA: Hematocrit on admission 24.4 32.9 on[**1-2**].4 on [**1-3**].5 on [**1-4**].2 on [**1-5**].Hemoglobin 11.5 on [**1-5**] white blood count 9.8 plateletcount 124000 INR 1.0 sodium 143 potassium 3.3 chloride101 CO2 30 BUN 17 creatinine 1.0 ALT AST totalbilirubin within normal limits CK 188 148 154 C troponinnegative Cortisol 53 CEA 25 H. pylori negative. Calciumphosphorus magnesium within normal limits.DISCHARGE DIAGNOSIS:1.
Peptic ulcer disease
DISEASE
.2. Upper GI bleed.3. Status post
pulmonary embolism
DISEASE
.4. Status post IVC filter.5. Hypertension.6. Anemia.7. Non-insulin dependent
diabetes mellitus
DISEASE
.8. Coronary
artery disease
DISEASE
.DISCHARGE MEDICATIONS: Protonix 40 mg po bid Clarithromycin500 mg po bid for 14 days Amoxicillin 1 gm po bid for 14days KCL 20 mEq po q d Captopril 12.5 mg po tid MagnesiumOxide 400 mg po bid Neutra-Phos one pack po qid Pravachol20 mg po q p.m. Accolate 20 mg po bid Lopressor 50 mg potid.Patient will be discharged to a rehabilitation hospital instable condition. [**Name6 (MD) 251**] [**Name8 (MD) **] M.D. [**MD Number(1) 1197**]Dictated By:[**Last Name (NamePattern1) 6063**]MEDQUIST36D: [**2174-1-7**] 08:32T: [**2174-1-7**] 11:05JOB#: [**Job Number 6064**]Admission Date: [**2174-6-8**] Discharge Date: [**2174-6-11**]Service: [**Location (un) **] General Medicine FirmHISTORY OF PRESENT ILLNESS: 85-year-old woman with historyof metastatic
pancreatic biliary cancer
DISEASE
who presents fromhome with 3-4 days of malaise with weakness. Her last bowelmovement was three days prior to admission. She hasdecreased urine output the prior two days no
chest pain
DISEASE
although she does have some
shortness of breath and abdominal
DISEASE
pain
DISEASE
over the past few days. She feels weak and has diffuse
aches
DISEASE
and
pains
DISEASE
. She has a history of
GI bleed
DISEASE
in thesetting of anticoagulation for
pulmonary embolism
DISEASE
. In[**2174-2-18**] she underwent embolization of a duodenal arteryby interventional radiology at that time. She has a large
pancreatic mass
DISEASE
requiring gastrojejunostomy done by Dr.[**Last Name (STitle) **] because of stricture/obstruction. She has notnoticed any
melena
DISEASE
or bright red blood per rectum. In theEmergency Room she was with blood pressure 80/60 hematocrit12.5 received one liter of normal saline one unit of packedred blood cells. EGD showed
bleeding
DISEASE
of a
pancreatic mass
DISEASE
inthe stomach. Patient and family wanted to proceed with IRintervention.PAST MEDICAL HISTORY: Metastatic
pancreatic cancer
DISEASE
biliarycancer with
mets
DISEASE
to the liver diagnosed in [**2-19**] during GJtube placement with liver biopsy.
Pulmonary embolism
DISEASE
statuspost IVC filter placement in [**2173-12-18**]. GI bleed in thesetting of anticoagulation for
pulmonary embolism
DISEASE
.
Hypertension
DISEASE
.
Diabetes mellitus
DISEASE
type 2 coronary arterydisease status post MI status post cholecystectomy chronic
obstructive pulmonary disease
DISEASE
.ALLERGIES: No known
drug allergies
DISEASE
.MEDICATIONS: Calcium carbonate 1 gm tid Captopril 150 mg potid Reglan 10 mg po tid Metoprolol 50 mg po bid Zantac 150mg po bid Ativan .25 mg po q 8 hours prn Darvocet twotablets po prn OxyContin 20 mg po bid prn Ambien 5 mg po qh.s. prn Glucotrol 5 mg po bid.SOCIAL HISTORY: No tobacco or alcohol use she immigrated 9years ago.FAMILY HISTORY: Father had
esophageal cancer
DISEASE
mother had a
stroke
DISEASE
brother has
lung cancer
DISEASE
.PHYSICAL EXAMINATION: On admission is notable fortemperature 97.7 pulse 79 blood pressure 94/63respirations 15. 100% sat on room air. In general alertand oriented times three no acute distress Russianspeaking. HEENT: Pupils are equal round and reactive tolight
extraocular movements
DISEASE
intact oropharynx clear rightIJ line in place no
lymphadenopathy
DISEASE
. Heart tachycardic nomurmurs rubs or gallops. Chest is clear to auscultationbilaterally no wheezes or rales. Abdomen soft nontender
active bowel sounds
DISEASE
positive
ascites
DISEASE
. Extremities no
edema
DISEASE
dorsalis
pedis
DISEASE
pulses Admission Date: [**2100-11-8**] Discharge Date: [**2100-11-14**]Date of Birth: [**2021-9-7**] Sex: FService: CSUMs. [**Known lastname 174**] is a direct admission to the operating room foraortic valve surgery. She was seen in preadmission testingprior to her scheduled surgery. At the time of visit inpreadmission testing the patient's physical exam is asfollows.CHIEF COMPLAINT: Asymptomatic patient.HISTORY OF PRESENT ILLNESS: A 79-year-old woman with knownAS x 9 years followed by serial echoes the last echo withworsening
aortic stenosis
DISEASE
and a diminishing aortic valvearea referred for cath and followed by aortic valvereplacement. The patient had an echo done in [**2100-8-29**]that showed an EF of 60 percent with an aortic valve area of0.9 and a peak gradient of 96 and a mean gradient of 60with mild
LVH
DISEASE
1 plus AI and 1 plus TR. She had a cardiaccath done [**10-5**] that showed an aortic valve gradient of56 with an aortic valve area of 0.5 cm2 an EF of 56percent RCA 40 percent left main 20 percent and an LAD 30percent lesion.PAST MEDICAL HISTORY:
Hypertension
DISEASE
.
Aortic murmur
DISEASE
.
Hiatal hernia
DISEASE
.GERD.Diverticulosis.Hernia repair in [**2034**].
Cataract
DISEASE
surgery in [**2096**].D and C in [**2071**].Drainage of a
thyroid cyst
DISEASE
approximately 10 years ago.MEDS AT ADMISSION:1. Cardizem CD 240 once daily.2. Hydrochlorothiazide 12.5 once daily3. Lipitor 10 once daily.4. Niferex 150 once daily.5. Calcium.6. Glucosamine.7. Metamucil.ALLERGIES: The patient states environmental
allergies
DISEASE
aswell as codeine although her reaction is simply
confusion
DISEASE
.FAMILY HISTORY: Mother died of CAD in her 70s. Father diedof CAD late in life.SOCIAL HISTORY: She lives with her husband. She deniestobacco use. Occasional alcohol use. No other recreationaldrug use.REVIEW OF SYMPTOMS: Noncontributory.PHYSICAL
EXAM
DISEASE
: VITAL SIGNS: Heart rate 86 blood pressure124/80 respiratory rate 20 height 5 feet 0 inches weight138 pounds. GENERAL: Sitting up in chair no acutedistress. SKIN: Warm
dry
DISEASE
and intact. No lesions. HEENT:Pupils equally round and reactive to light. Extraocularmovements intact. Neck is supple with no JVD and no
bruits
DISEASE
but she does have a radiated murmur. Chest is clear toauscultation bilaterally. Heart regular rate and rhythm witha IV/VI systolic ejection murmur. Abdomen is softnontender nondistended with
normoactive bowel sounds
DISEASE
.Extremities are warm and well-perfused with 1-2 plus
edema
DISEASE
right greater than left. VARICOSITIES: None.Neurologically alert and oriented x 3. Nonfocal exam.PULSES: Femoral 2 plus bilaterally. Dorsalis pedis 1 plusbilaterally. Posterior tibial 1 plus bilateral. Radial 2plus bilaterally.Carotid ultrasound showed less than 40 percent stenosisbilaterally.LABS: White count 4.5 hematocrit 32 platelets 234 PT12.8 INR 1.0 sodium 139 potassium 3.2 chloride 100 CO228 BUN 16 creatinine 0.8 glucose 122 ALT 13 AST 22 alkphos 82 amylase 78 total bili 0.5 albumin 4.0 hemoglobinA1C 5.1. Chest x-ray showed no
CHF
DISEASE
or
pneumonia
DISEASE
.HOSPITAL COURSE: On [**11-8**] the patient was directlyadmitted to the operating room where she underwent an aorticvalve replacement with a number 23 mm [**Last Name (un) 3843**]-[**Doctor Last Name **]tissue valve. Her bypass time was 142 minutes with acrossclamp time of 102 minutes. She tolerated the operationwell and was transferred from the operating room to theCardiothoracic Intensive Care Unit. At the time of transferthe patient was in a normal sinus rhythm at 85 beats perminute with a mean arterial pressure of 67 and a CVP of 15.She had propofol at 20 mcg/kg/min and Neo-Synephrine at 0.15mcg/kg/min.The patient did well in the immediate postoperative period.Her anesthesia was reversed. She was weaned from theventilator and successfully extubated. Throughout thatperiod she remained hemodynamically stable as she didthroughout the operative day. However she did require aNipride drip to maintain a blood pressure between 100 and110.On postoperative day 1 the patient continued to behemodynamically stable. She was begun on oral medicationsand weaned off of her Nipride drip. Additionally her chesttubes were removed and she was transferred to the floor forcontinuing postoperative care and cardiac rehabilitation.Once on the floor the patient had an uneventful hospitalcourse. Her activity level was increased with the assistanceof the nursing staff as well as physical therapy.On postoperative day 3 her temporary pacing wires and herFoley catheter were removed. Over the next 2 days heractivity level was further advanced with nursing and physicaltherapy assistance and on postoperative day 6 it wasdecided that the patient was stable and ready to bedischarged to home.DISCHARGE VITALS: Temperature 98.3 heart rate 81--sinusrhythm blood pressure 128/66 respiratory rate 22 O2 sat 94percent on room weight preoperatively 63 kg at discharge60.1 kg.LAB DATA: Hematocrit 29.4 sodium 142 potassium 3.5chloride 102 CO2 34 BUN 16 creatinine 0.8 glucose 98.DISCHARGE PHYSICAL
EXAM
DISEASE
: NEURO: Alert and oriented x 3.Moves all extremities. Follows commands. Nonfocal exam.RESPIRATORY: Lungs clear to auscultation bilaterally.CARDIAC: Regular rate and rhythm S1 S2 with no murmur.Sternum is stable. Incision with Steri-Strips open to airclean and
dry
DISEASE
. Abdomen is soft nontender nondistended withnormoactive bowel sounds. Extremities are warm and well-perfused with no
edema
DISEASE
.Th[**Last Name (STitle) 1050**] is to be discharged to home with visiting nurses.She is to have follow-up with Dr. [**Last Name (STitle) 6073**] in [**3-2**] weeks andfollow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks. Additionally sheis to have follow-up with her primary care doctor [**First Name (Titles) **][**Last Name (Titles) 5887**] once she returns to [**State 5887**].DISCHARGE DIAGNOSES: Status post aortic valve replacementwith a number 23 [**Last Name (un) 3843**]-[**Doctor Last Name **] tissue valve.
Hypertension
DISEASE
.
Gastroesophageal reflux disease
DISEASE
.Diverticulosis.Hernia repair.
Cataracts
DISEASE
.DISCHARGED MEDICATIONS:1. Metoprolol 50 mg [**Hospital1 **].2. Colace 100 mg [**Hospital1 **].3. Aspirin 325 once daily.4. Percocet 5/325 1-2 tabs q 4-6 hr prn.5. Atorvastatin 10 mg once daily.6. Niferex 150 mg once daily. [**Doctor Last Name **] [**Last Name (Prefixes) **] M.D. [**MD Number(1) 1288**]Dictated By:[**Last Name (NamePattern4) 1718**]MEDQUIST36D: [**2100-11-15**] 17:55:55T: [**2100-11-16**] 10:57:54Job#: [**Job Number 6074**]Admission Date: [**2188-7-19**] Discharge Date: [**2188-7-22**]Service:HISTORY OF PRESENT ILLNESS: The patient is an 82 year oldmale who underwent a screening endoscopy and colonoscopy on[**2188-7-18**]. During the procedure polypectomy was performed ona
polyp
DISEASE
seen in the left ascending colon. The patient wasdischarged home and on the morning of admission developedbrisk bright blood per rectum and
syncope
DISEASE
when he stood upfrom his bed. He presented to the Emergency Department atwhich time he was found to be
hypotensive
DISEASE
with a systolicblood pressure in the 60's. He was immediately resuscitatedfor
hypovolemic shock
DISEASE
.The patient also underwent nasotracheal intubation in theEmergency Room for airway protection.PAST MEDICAL HISTORY: Significant for
prostate cancer
DISEASE
basalcell carcinoma colonic
polyp hiatal hernia
DISEASE
gastroesophageal reflux disease
DISEASE
.PAST SURGICAL HISTORY: Significant for bilateral inguinal
hernia
DISEASE
repairs. Status post XRT for
prostate cancer
DISEASE
and aprevious transurethral resection of prostate.MEDICATIONS ON ADMISSION: None.ALLERGIES: None.SOCIAL HISTORY: There is no history of tobacco or ETOH use.PHYSICAL EXAMINATION: The patient was intubated and sedated.Heart rate was 90Admission Date: [**2176-10-19**] Discharge Date: [**2176-10-22**]Date of Birth: [**2102-3-3**] Sex: FService: MEDICINE
Allergies
DISEASE
:ZosynAttending:[**First Name3 (LF) 5606**]Chief Complaint:
dyspnea
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Ms. [**Known lastname 6083**] is a 74 y/o female with a history of
COPD
DISEASE
dCHF CADs/p MI in [**2167**] who presents with
intermittent confusion
DISEASE
sincethursday and shortness on breath since the night PTA. She usedher nebs at home without relief. According to her daughter shehas been requiring more pillows at night but denied any PND.
Denies fevers chills cough nausea vomiting chest pain
DISEASE
. Doesnote left arm
pain
DISEASE
which is her
anginal
DISEASE
equivalent intermittentsince thursday. She denied any sick contacts however notes thatshe has not been compliant with a low salt diet. She notes thather weight has not changed..In the ED initial VS were: 97.8 96 181/61 20 89%
RA
DISEASE
. EKG showedsinus 81 [**Last Name (LF) **] [**First Name3 (LF) **] dep I
AVL
DISEASE
V5-6 (Admission Date: [**2176-12-16**] Discharge Date: [**2177-1-5**]Date of Birth: [**2102-3-3**] Sex: FService: SURGERY
Allergies
DISEASE
:Zosyn / Penicillins / DilantinAttending:[**First Name3 (LF) 6088**]Chief Complaint:AAAMajor Surgical or Invasive Procedure:[**2176-12-16**]1. Bilateral common femoral artery cutdown.2. Right common iliac artery and external iliac artery stent grafts with angioplasty.3. Abdominal aortogram.4. Aorta right uniiliac endograft.5. Right iliofemoral bypass with Dacron.6. Right to left femoral-to-femoral bypass graft with polytetrafluoroethylene (PTFE).7. Coil embolization of the right hypogastric artery.8. Coil embolization of the left common iliac artery.History of Present Illness:74F with a known 5.3x7.2cm AAA presented to her PCP for [**Name Initial (PRE) **] noncontrast CT screening test secondary to recent
weight loss
DISEASE
whichrevealed
enlargement of the aneuysm
DISEASE
. She was referred to Dr.[**Last Name (STitle) **] for further evaluation and contrast enhanced CT revealed a6.6x9.0cm
aneurysm
DISEASE
. Given the findings of
enlargement COPD
DISEASE
andirregular shape she was at a high risk for
rupture
DISEASE
. Alsosecondary to her comorbidities she was not an open repaircandidate. She was then evaluate for endovascular repair forwhich her imaging was sent for three-dimensional reconstructionand a suitable endovascular option was found. She agreed to theprocedure given the risks of
renal failure
DISEASE
requiring dialysis
respiratory failure
DISEASE
and
death
DISEASE
.Past Medical History:-
Coronary artery disease
DISEASE
- negative MIBI in [**8-8**]. s/p MI in[**2167**] and has Admission Date: [**2122-3-3**] Discharge Date: [**2122-3-7**]Date of Birth: [**2073-6-1**] Sex: FService: MEDICINE
Allergies
DISEASE
:Sulfonamides / Hydrochlorothiazide / Lipitor / Zocor /Glucophage / Neurontin / Lasix / Lyrica / Tylenol/Codeine No.3Attending:[**First Name3 (LF) 905**]Chief Complaint:
hyperkalemia ARF
DISEASE
Major Surgical or Invasive Procedure:CTA of the chest (showed evidence of
Pneumonia
DISEASE
)CT of the head (normal)History of Present Illness:48 year old female with hx of DMII now presenting to ER due tooutside blood work yesterday showeing K of 6.0 at her annualphyscial and an elevated Cr to 1.7. It was rechecked today andstill elevated depsite today stopping her ACEI and aldactone.She was instructed to go the ER. While in ER pt felt like hersugar was low and had a fs of 56 she was given detrose and BSimproved to 87. She reports that she previously had bs alwaysAdmission Date: [**2177-4-14**] Discharge Date: [**2177-4-18**]Date of Birth: [**2098-11-22**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 4095**]Chief Complaint:HypoxiaPosterior hip
dislocation
DISEASE
Major Surgical or Invasive Procedure:Reduction of left posterior hip
dislocation
DISEASE
PICC line insertionHistory of Present Illness:78M with hx of CABG in [**2168**] CAD DM hx of hip frequent
dislocation
DISEASE
of artificial L hip tripped over rug in apartmentand fell no Head strike or LOc. He felt hip [**Doctor Last Name **] out. In the EDinitial VS were:97.3 108 144/75 16 no O2 sat recorded 3LNC(recorded).However resident noted patient to be
tachypneic
DISEASE
at35 hypoxic to 50. Patient did note several hours of shortness ofbreath today upon further questioning. CXR showed R pulmonary
edema
DISEASE
vs infiltrate placed on NRB then sats to mid90s-100. ACT scan was negative for PE but did show right sided
pneumonia
DISEASE
possible aspiration. Patient noted to have elevated lactate 4.4.WBC 2.8 with N:59.5 L:33.2 M:5.4 E:0.9 Bas:1.0.Vanc/Zosyn/Levoflox given. Trop of 0.05. EKG: sinus 92 NA IVconduction delay ST
depression
DISEASE
I and aVL..In ED Ortho consulted and patient had procedural sedation withwith fent (100)/versed (4) hip successfully reduced in ED.Reversed sedation with flumazenil (0.2)/narcan (2) Got 2L IVfluids for the lactate..On arrival to the MICU patient's VS. 97.7/ 81/112/69/13 100%NRB. On recheck 91% on
RA
DISEASE
. 97% on 2L. patient denied any Chestpain/SOB. Feels very well and is surprised to be admitted.Past Medical History:
Coronary artery disease
DISEASE
status post CABG [**2168**]
Diabetes
DISEASE
recently stopped glyburide and metformin per his doctor[**First Name (Titles) **][**Last Name (Titles) 6093**]
muscle weakness
DISEASE
NOSspinal stenosis lumbarMITRAL INSUF/AORT STENOSPVD NOSHLSocial History:Social History: Lives by himself. Has a home care nurse [**First Name (Titles) **] [**Last Name (Titles) 6094**]s every 2 weeks. Uses a walker or cane and scooter when outof apartment. No smoking no alcohol no rec drugs. has a Niece[**Name (NI) **] [**Name (NI) **] who lives in [**Hospital1 1474**] [**Telephone/Fax (1) 6095**] (cell)[**Telephone/Fax (1) 6096**] (work) is HCP according to patient.Family History:Family History: Father with MI in 50s. Brother with MI in 50s.No history of
cancer
DISEASE
Physical Exam:Vitals: 97.7/ 81/112/69/13 100% NRBGeneral: Alert oriented x3 no acute distress NRB in placeHEENT: Sclera anicteric MMM oropharynx clear EOMI PERRLNeck: supple JVP not elevated no LADCV: Regular rate and rhythm normal S1 Admission Date: [**2154-3-24**] Discharge Date: [**2154-3-28**]Date of Birth: [**2084-12-30**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:
Shortness of Breath
Major Surgical
DISEASE
or Invasive Procedure:NoneHistory of Present Illness:69 yo M h/o
HIV COPD
DISEASE
presenting with
shortness of breath
DISEASE
andAdmission Date: [**2108-3-8**] Discharge Date: [**2108-3-16**]Date of Birth: [**2047-10-22**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1505**]Chief Complaint:CP and
fatigue
DISEASE
Major Surgical or Invasive Procedure:s/p CABGx3(LIMA-Admission Date: [**2114-7-13**] Discharge Date: [**2114-7-20**]Date of Birth: [**2034-8-12**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 613**]Chief Complaint:Pt transferred from OSH for treatment of
odontoid fracture
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:Mr. [**Known lastname 6105**] is a 79yo male with PMH significant for
CHF
DISEASE
atrial
fibrillation
DISEASE
and CRI who presents from OSH with odontoid
fracture
DISEASE
s/p mechanical fall. Per patient he fell on Thursdayafter he tried to get up from his bed. He admits to hitting hishead on the floor. He was brought to [**Hospital **] [**Hospital 1459**] Hospitaland was found to have an
odontoid fracture
DISEASE
. He was transferredto [**Hospital1 18**] for further work-up..In the [**Hospital1 18**] ED his initial vitals were T 96.2 BP 81/60 AR 106RR 16 O2 sat 92%
RA
DISEASE
. He received Levaquiin 750mg IV x1 and wasstarted on Levophed which was turned off upon transfer to thefloor. He had repeat imaging which confirmed the
fracture
DISEASE
. Hedenies any
fevers chills chest pain
DISEASE
SOB
dizziness
DISEASE
abdominal
pain
DISEASE
or bloody/black tarry stools. He does admit to aproductive
cough
DISEASE
over the past 3-4 weeks..Of note patient was recently admitted to [**Hospital **] [**Hospital 1459**]Hospital from [**Date range (1) 6106**] after he oresented with history ofrecurrent
dizziness
DISEASE
and his blood pressure was found to be inthe low 70's. He underwent several studies including a Holtormonitor echo and PFTs. He was suggested to be discharged torehab but the patient refused.Past Medical History:1)Hypertension2)Atrial
fibrillation
DISEASE
s/p ICD placement Admission Date: [**2193-3-27**] Discharge Date: [**2193-4-3**]Date of Birth: [**2154-3-3**] Sex: MService:ADMISSION DIAGNOSIS: Klebsiella bacteremia/pneumonia.HISTORY OF PRESENT ILLNESS: This is a 39-year-old gentlemanwith
acquired immunodeficiency syndrome
DISEASE
with
fevers rigors
DISEASE
and
chills
DISEASE
times three days. Status post foscarnet infusionvia Port-A-Cath. Abdominal
pain
DISEASE
last prior to discharge in[**Hospital6 733**]. Blood cultures times two andMycobacterium avium-intracellulare cultures were drawn.In the Emergency Department hypoxic at 87%. Temperatures hadranged between 99 to 103.8.
Cough
DISEASE
at baseline secondary tochronic sinusitisAdmission Date: [**2193-12-19**] Discharge Date: [**2193-12-24**]Date of Birth: [**2154-3-3**] Sex: MService: MEDICINE
Allergies
DISEASE
:Sulfamethoxazole/Trimethoprim / LisinoprilAttending:[**First Name3 (LF) 6114**]Chief Complaint:
fever
DISEASE
to 103 degress
chills fatigue vomiting
DISEASE
x 1 dayMajor Surgical or Invasive Procedure:noneHistory of Present Illness:HPI: 39 year old man with
AIDS
DISEASE
CD4 of 4 in [**4-29**] VL not donewho presented to the ED with 1 day of
fevers
DISEASE
to 103 degrees athome
rigors
DISEASE
and
chills
DISEASE
. On day of admission he also had 1episode of
nausea
DISEASE
vomited up food (non-bilious/ non-bloody)that has resolved. Pt. notes chronic
cough
DISEASE
he associated withhis thrush. Also had episode of
diarrhea
DISEASE
5 days ago thatresolved. Otherwise the patient denies
headache
DISEASE
visualchanges neck pain/stiffness confusion
chest pain
DISEASE
SOBpleuritic CP abdominal pain (has
chronic tenderness
DISEASE
epigastrically) urinary changes new
rash
DISEASE
or
joint pain
DISEASE
..On arrival to the ED he was found to have a temperature of 102.9degrees HR in 130s SBP 106/61. Also was found to have alactate of 7.7 bicarb of 15 (normally in 20s)
ARF
DISEASE
with cr of2.5 (baseline 1.1-1.4). He was put on the MUST protocol and aleft subclavian line was placed. His initial CVP was 4. Mixedvenous sat was 85%. Blood cultures were drawn which grew [**2-28**]bottles gram negative rods. He received doses of vanc/levo. HisBP dropped to 70/30 and he received 5 L of NS levophed startedafter 3 L and SBP 85. A-line placed - ABG - 7.40/26/137 and thelactate improved to 1.5. He started making urine with up to 60cc per hour. He was admitted to the MICU.He was continued on the
sepsis
DISEASE
protocol in the MICU andtransfused with 2 units of blood for a HCT of 18. He was weanedfrom levophedrine around 4 am and has since had a stable BP inthe 110's.Patient was then transferred to floor on [**12-20**] at that time hereported feeling much improved but not quite at his baseline.He denies continued
fevers
DISEASE
or
chills abdominal pain diarrhea
DISEASE
nausea vomiting
DISEASE
or other concerns. He says he is currentlyalmost blind from the
CMV retinitis
DISEASE
and [**Doctor Last Name **] detect some lightin his left eye.Past Medical History:1. HIV since '[**77**] now with
AIDS
DISEASE
CD4 of 4 complicated byKlebsiella oxytoca pna with pos. BCX (pan-[**Last Name (un) 36**]) [**Last Name (un) 6108**]
bacteremia
DISEASE
in [**6-28**] cytomegalovirus
retinitis
DISEASE
currently [**Doctor Last Name **]oroesophageal
candidiasis
DISEASE
oral hairy leukoplasia toxo in [**2184**]
anal warts lipodystrophy
DISEASE
.2.
Dermatitis
DISEASE
.3.
Hypertension
DISEASE
.4. Hemorrhoids.5.
Anemia
DISEASE
.6.
Leukopenia
DISEASE
.7.
Angioedema
DISEASE
.8. Ulcerations.9.
Herpes simplex
DISEASE
.10. Shingles.11.
Hepatitis B.
DISEASE
12. Bacterial
meningitis
DISEASE
.13. EF of 45%14.
peripheral neuropathy
DISEASE
Social History:Lives in JP with his male partner. Denies current alcohol use.Smoked 1 ppd for 15 years quit in [**2179**]. Used to use marjuananow on marinol. No IVDA.Family History:father had MI at age 41mother had
salivary cancer
DISEASE
in her 60'sPhysical Exam:V: Tm 102.9 Tc 97.7 P 85 BP 109/69 R20 99%
RA
DISEASE
Gen:
cachectic
DISEASE
blind pleasant man in no apparent distressSkin:
molluscum contagiosum
DISEASE
over face. Port-o-cath R chestnontender no erethemaHEENT: pupils 3mm and equal but not reactive to light. OP withthrush over
palate
DISEASE
and tongueResp: CTAP BCV: RRR nl s1s2 II/VI SEM at RUSBAbd: soft NTND Admission Date: [**2194-2-1**] Discharge Date: [**2194-2-7**]Date of Birth: [**2154-3-3**] Sex: MService: MEDICINE
Allergies
DISEASE
:Sulfamethoxazole/Trimethoprim / LisinoprilAttending:[**First Name3 (LF) 30**]Chief Complaint:39y/o M with HIV/AIDS last CD4 count 4 blind [**1-29**] CMV
retinitis
DISEASE
hep B presents with
fatigue
DISEASE
and
fever
DISEASE
to 103 at home.Major Surgical or Invasive Procedure:1. removal of Portacath2. placement of triple lumen central catheterHistory of Present Illness:Pt felt tired in the day prior to admission with decreasedappetite. Developed
fever
DISEASE
to 103F. Denies
nausea vomiting
DISEASE
chills abdominal pain
DISEASE
or
diarrhea
DISEASE
. Denies dysuria nasal
congestion chest congestion
DISEASE
. Denies headacheAdmission Date: [**2198-1-22**] Discharge Date: [**2198-2-4**]Date of Birth: [**2137-3-19**] Sex: MService:HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 6123**] was a 60-year-oldright handed African American male who was admitted on[**2198-1-22**] with history of
acute left weakness
DISEASE
. He had a pastmedical history of
diabetes coronary artery disease
DISEASE
andprior
stroke
DISEASE
. He presented to the Emergency Room with suddenonset left sided weakness said by report occurringapproximately 30 minutes before presenting to the EmergencyRoom. The patient was a patient of Dr. [**Last Name (STitle) 6124**] and thepatient stated at that moment he takes Coumadin for prior
strokes
DISEASE
.The patient vomited and aspirated coming back from CT scanand drove his O2 saturation transiently to the 60s requiringintubation for airway protection.PAST MEDICAL HISTORY:1.
CVA
DISEASE
in [**2193**] with right sided dysmetria left parietal
stroke
DISEASE
in [**2192**] with left supraclinoid IC stenosis.2.
Diabetes
DISEASE
.3.
Hypertension
DISEASE
.4.
Coronary artery disease
DISEASE
.MEDICATIONS ON PRESENTATION: He said that he took Coumadinand he could not remember the rest of his medications.PHYSICAL EXAMINATION IN THE EMERGENCY ROOM: He presentedwith a blood pressure of 190/118 temperature of 96.8 andsaturation of 97%. General: The patient appeared statedage lying in bed looking to the right in no acute distress.HEENT: Normocephalic atraumatic sclerae white. Neck:Supple. Lungs: Clear to auscultation bilaterally.Cardiovascular: Regular rate and rhythm normal S1 S2 nomurmurs gallops or rubs. Abdomen: Normal bowel soundssoft nontender nondistended. Extremities: Warm no
clubbing cyanosis
DISEASE
or
edema
DISEASE
. Neurologic examination in theEmergency Room: Cognitive: He was awake alert but notfully cooperative. Able to state his name but he was notable to distinct that there was any problem with him at thatpoint. He was able to name objects follow simple commandswith possible perseveration. Speech: Normal voice qualityarticulation comprehension. Fluent without paraphasias.Cranial nerves: Face with left lower droop. Extraocularmovements gaze deviation to the right but was able to lookto the midline and past midline to the left. Gaze appearsconjugate. Visual fields possibly decreased but treads onthe left. Pupils are reactive to light directly andconsensually and accommodation. Palate was symmetric andtongue was midline. Hearing is grossly intact. Sensationdifficult to assess. Motor examination: He was able to showhis left thumb and squeeze left hand on command. He was notable to lift left arm against gravity. He was able to raisehis left leg against gravity but was not able to move hisleft foot on command. He was able to raise right arm legand moves foot without difficulty. Reflexes were Admission Date: [**2118-10-6**] Discharge Date: [**2118-10-9**]Service: MEDICINE
Allergies
DISEASE
:MorphineAttending:[**First Name3 (LF) 2972**]Chief Complaint:
Dyspnea cough
DISEASE
Major Surgical or Invasive Procedure:ICU monitoring TTE CT scan chest transfused 1U PRBCsHistory of Present Illness:The patient is an 87 year old female with history of coronary
artery disease
DISEASE
and
congestive heart failure
DISEASE
(EF 34% in [**2114**]) whopresents with
cough
DISEASE
of 2 week duration productive of whitesputum and increasing
shortness of breath
DISEASE
at rest as well as
dyspnea
DISEASE
on exertion. She also reports some
orthopnea
DISEASE
--she hasslept upright for years. No recent CP abd
pain
DISEASE
fevers N/V/Dblack or bloody stools. Taking good POs. Intermittent leg
swelling
DISEASE
none today..In ED initial VS: T98.3 HR 110 BP 116/68 RR 33 SaO2 98% on2 L NC. CXR showed mild to moderate
CHF
DISEASE
. Levaquin 750 given.Initial CK flat trop 0.02. BNP 15000. Lactate 3. EKG changedfrom prior.Past Medical History:1. CAD s/pMI [**2110-3-4**] cath showed right coronary artery thatwas dominant with 100% mid occlusion which was stented LAD had a50-70% stenosis mid portion Obtuse marginal 1 was totallyoccluded2. total abdominal hysterectomy3. SBO with resection4. Right CEA [**2110**]5.
DVT
DISEASE
on coumadin6.
Pelvic fracture
DISEASE
s/p fall7.
B12 deficiency anemia
DISEASE
Social History:Lives with son. She walks with a cane. She denies currenttobacco but with a 50 pack year history.Family History:Non-contributory. No
osteoporosis
DISEASE
.Physical Exam:VS (on arrival to MICU): T 99.4 HR 120 --Admission Date: [**2101-6-30**] Discharge Date: [**2101-7-7**]Date of Birth: [**2023-9-16**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 613**]Chief Complaint:
Hypoglycemia hypotension
DISEASE
Major Surgical or Invasive Procedure:Central venous catheter placement.History of Present Illness:Ms. [**Known lastname 6129**] is a 77yo female with PMH significant for
COPD
DISEASE
on 4LNC
HTN anemia
DISEASE
and recent
pubic ramus fracture
DISEASE
who is beingtransferred to the MICU for
hypotension hypoxemia
DISEASE
and
hypoglycemia
DISEASE
. Per her family she fractured her pubic ramus 3weeks ago. She was evaluated at the [**Hospital1 756**] and was found to bea non-surgical candidate. She was then transferred to [**Hospital 882**]Hospital and admitted. During her stay she was found to have a
UTI
DISEASE
and was treated with Cipro. Her daughter states that after 5days of treatment she found out that the bug in her urine wasresistent to the Cipro. She was then apparently treated withCefpodoxime and the last day was [**6-19**]. She had a foley in placeduring these times which was removed yesterday. Two days afterbeing at the NH she represented to [**Hospital1 882**] ED with symptomssuggestive of a
bowel obstruction
DISEASE
. Of note she has been onnarcotics during this time. She was then discharged back toBostonian where she has been since [**6-18**]. Per daughter she hashad poor intake over the past few days.At 8:15am this morning her BS was low according to theglucometer. She was immediately given Glucagon IM and glucosegel. Her BS increased to 40 at 8:50am after a second glucagonshot. Blood sugar remained at 42 per nurse [**First Name (Titles) **] [**Last Name (Titles) **]. EMS was calledand she was immediately brought to [**Hospital1 18**].In the ED initial vitals were T 98.2 BP 119/70 AR 78 RR 28 O2
sat 80%
RA
DISEASE
. She was immediately placed on
NRB
DISEASE
and her O2
saturation increased to 92%. Repeat blood sugar was 135. Shereceived ASA 325mg Levaquin 750mg IV Flagyl 500mg IV Zofran4mg IV and 3L normal saline. She was then transferred to theMICU for further management.Past Medical History:1)Pubic ramus
fracture
DISEASE
2)Syncope3)COPD on 4L at home4)IDDM5)Hypertension
6)Anemia
DISEASE
(followed by hematologist)Social History:Patient lives with husband. [**Name (NI) **] current tobacco alcohol orIVDA.Family History:NCPhysical Exam:vitals T 95.6 BP 161/84 AR 89 RR 20 O2 sat 86% on 6L NCGen: Awake responsive to commands increased respiratory effortHEENT: Mucous membranes slightly dryHeart: RRR no audible mrgLungs: CTAB Admission Date: [**2101-7-8**] Discharge Date: [**2101-7-29**]Date of Birth: [**2023-9-16**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2297**]Chief Complaint:
Hypotension
DISEASE
Major Surgical or Invasive Procedure:Endotracheal intubation x 2Central venous linePICC linePleurocentesisArterial lineDC cardioversionHistory of Present Illness:Ms. [**Known lastname 6129**] is a 77yo female with PMH significant for
COPD
DISEASE
on 4LNC
HTN anemia
DISEASE
and recent
pubic ramus fracture
DISEASE
who wasrecently in the MICU for
hypoxia hypotension
DISEASE
and thought tohave
urosepsis
DISEASE
. At that time she was stared on broad spectrumantibiotics (Vancomycin/Cefepime) and narrowed to cefpodoxime ondischarge to complete a 7-day course. She was discharged torehab on [**2101-7-7**]. At rehab on [**2101-7-8**] she was found byfamily members to be lethargic somnolent and
tachypneic
DISEASE
. Shewas transferred to [**Hospital1 18**] for further evaluation.In the ED initial vitals were T:97.9 BP:70/38 HR:73 RR:16O2Sat:97% on
RA
DISEASE
. For the
hypotension
DISEASE
she was given 5 litresresuscitative crystalloid and a left IJ central line was placedafter unsuccessful attempt at right IJ. Patient was also foundto have
abdominal tenderness
DISEASE
and an abdominal CT scan wasordered and per our wet read showed
dilated colon
DISEASE
with stoolthroughout. She was given Vancomycin andPiperacillin-Tazobactam x 1 dose after blood and urine cultureswere sent. She was then transferred to MICU.Past Medical History:1)Pubic ramus
fracture
DISEASE
2)Syncope3)COPD on 4L at home4)IDDM5)Hypertension
6)Anemia
DISEASE
(followed by hematologist)Social History:Patient lives with husband [**Name (NI) 6132**] recently discharged to a rehabone day prior. No current tobacco alcohol or IVDA.Family History:NCPhysical Exam:vitals T 97.1 BP 103/46 HR 70 RR 19 O2 sat 94% on 4 L NCGen: Awake responsive to commands breathing comfortablyHEENT: Mucous membranes dryHeart: RRR no audible mrgLungs: CTAB diminished breath sounds bilaterallyAbdomen: Soft distended tympanic sounds throughout withpercussion tender to palpation diffusely no rebound orguardingExtremities: 1Admission Date: [**2188-8-5**] Discharge Date: [**2188-8-18**]Date of Birth: [**2122-1-10**] Sex: MService: MEDICINE
Allergies
DISEASE
:AtenololAttending:[**First Name3 (LF) 759**]Chief Complaint:bright red blood per rectumMajor Surgical or Invasive Procedure:None.History of Present Illness:66 yo M with mechanical AVR on [**First Name3 (LF) **] with aortic valveenterococcal
endocarditis
DISEASE
and ring abscess and recent
GIB
DISEASE
([**2188-8-4**]) after colonic polypectomy s/p 7 units pRBC and INRreversal who was transferred to [**Hospital1 18**] MICU for management of
hypotension
DISEASE
and AVR abscess..On arrival in the MICU his
hypotension
DISEASE
had been resolved. HisHct remained stable and he was placed on heparin drip foranticoagulation. His EKG showed PR prolongation to 400 msec.Repeat TEE showed heterogeneous thickening of the peri-aortictissue consistent with an aortic root abscess. EPcardiothorasic surgery and ID were consulted. EP and CSURG feltthat this could be conservatively managed until surgery andrecommends rehab with regular EKG. ID recommended amp Admission Date: [**2154-4-9**] Discharge Date: [**2154-4-18**]Date of Birth: [**2084-12-30**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 2186**]Chief Complaint:
Respiratory distress
DISEASE
Major Surgical or Invasive Procedure:BiPapIntubation extubation ([**2154-4-13**])History of Present Illness:69 year old male with history of HIV (CD4 116 [**2154-4-8**])
COPD
DISEASE
(2-4L at home)
DVT
DISEASE
on coumadin hypertension chronic lowerback [**Last Name (un) 2187**]
osteoporosis
DISEASE
who presents with
respiratory distress
DISEASE
.The patient had been recently admitted 5/13-16/[**2153**] for
COPD
DISEASE
exacerbation and treated with nebs azithromycin prednisone(slow taper). The patient presented to the ED on [**2154-4-2**] for
dyspnea
DISEASE
but left AMA before admission. He was sent to the ED on[**2154-4-8**] but left AMA again with prednisone and azithromycinprescriptions which he never filled. He had seen Dr. [**Last Name (STitle) **] inpulmonary clinic yesterday and had been non-compliant withprednisone taper. He endorsed Admission Date: [**2188-10-6**] Discharge Date: [**2188-10-11**]Date of Birth: [**2122-1-10**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Atenolol / LisinoprilAttending:[**First Name3 (LF) 1505**]Chief Complaint:
Endocarditis
DISEASE
Major Surgical or Invasive Procedure:[**2188-10-7**] - Redo sternotomy Aortic valve replacement(21mm St.[**Male First Name (un) 923**] Regent Mechanical)/Closure of
aortic abscess
DISEASE
(Patchpericardium)/Ascending Aorta Replacement(28mm Gelweave graft).History of Present Illness:66M w h/o
bicuspid aortic valve s/p
DISEASE
mechanical AVR (on[**Male First Name (un) **])in [**2171**] at [**Hospital1 18**]. The ascending aorta was noted to be 4.5cm atthe time and was not replaced. He had an episode ofenterococcal aortic valve
endocarditis
DISEASE
in [**2187-11-13**].
Enterococcal endocarditis
DISEASE
was again diagnosed in [**2188-7-13**]withconcern for aortic valve ring abscess on echo. The patientwas evaluated for the source of his enterococcal
bacteremia
DISEASE
andmild
ischemic colitis
DISEASE
and several polyps were found. Apolypectomy was performed. An EGD found mild
gastritis
DISEASE
and hewasstarted on Pantprazole. The patient was discharged on ampicillinand gentamicin on [**2188-7-24**].He was admitted on [**2188-9-9**] for preoperative workup and cardiaccath. Cardiac cath did not reveal obstructive coronary lesiosn.On admission the patient exhibited gait instability andneurology was consulted. It was determined that the patient wasexperiencing
vestibulopathy
DISEASE
secondary to gentamycin. MRIrevealed very small microembolic
infarcts
DISEASE
which were attributedto his time off [**Date Range **] resulting in subtherapeutic INR orless likely
septic
DISEASE
emboli. Gentamicin was discontinued and thepatient was discharged home on ampicillin which will continueuntil surgery. ID has continued to follow him as an outpatientwith weekly blood cultures. The patient returns for heparinbridge preoperatively.Past Medical History:-Mechanical AVR [**3-/2172**]-Enterococcal
faecalis endocarditis
DISEASE
diagnosed in [**11-20**] AVR ringabscess diagnosed [**7-22**]-Hypertension-Hyperlipidemia-Ischemic
colitis
DISEASE
-Colonic polyps-GERD-Hiatal
hernia
DISEASE
-Gastritis-DiverticulosisSocial History:Lives with wife in [**Name (NI) 6134**] MA. Former smoker. Rare ETOH.Family History:Non-contributory.Physical Exam:Pulse:80 Resp:16 O2 sat:99%B/P Right:122/60 Left:122/64Height: 5'[**87**]Admission Date: [**2190-2-8**] Discharge Date: [**2190-2-15**]Date of Birth: [**2144-2-23**] Sex: MService: ENT SURGERYCHIEF COMPLAINT: Chronic aspiration.HISTORY OF THE PRESENT ILLNESS: This is a 45-year-old malewith
Down's syndrome
DISEASE
with frequent aspirations resulting inseveral episodes of aspiration
pneumonia
DISEASE
. The patient hashad a gastric feeding tube since [**2182-1-3**]. Aswallowing video fluoroscopy in [**2180**] revealed moderate tosevere
oropharyngeal swallowing disturbance
DISEASE
with aspirationafter the swallow and poor laryngeal sensitivity noted byabsent
cough
DISEASE
following the aspiration.PAST MEDICAL HISTORY:1.
Down's syndrome
DISEASE
with profound mental retardation.2.
Hepatitis B
DISEASE
carrier.3. Osteoporosis.4. Hiatal
hernia
DISEASE
.5.
Allergic rhinitis
DISEASE
.6. Constipation.7. Left
retractile testis
DISEASE
.8. Right hip
subluxation
DISEASE
.9.
Atopic dermatitis
DISEASE
.PAST SURGICAL HISTORY:1. Right total hip replacement in [**2188-6-2**].2. G tube placement in [**2182-1-3**].3. Excision of
thigh lipoma
DISEASE
in [**2182-5-4**].4. Left
cataract
DISEASE
extraction with lens implant.ALLERGIES: Keflex which causes a
rash
DISEASE
Reglan which causes
dystonia
DISEASE
and acetazolamide.ADMISSION MEDICATIONS:1. Protonix 40 b.i.d.2. Theophylline 200 q.p.m.3. Multivitamin.4. Milk of magnesia.5. Loratadine 10 mg every evening.6. Lactobacillus 40 b.i.d.SOCIAL HISTORY: The patient is a resident of [**Location 6151**]Developmental Center.PHYSICAL EXAMINATION ON ADMISSION: Cardiac: Regular rateand rhythm. Lungs: Clear to auscultation bilaterally.Abdomen: Soft nondistended nontender with a G tube inplace. Extremities: Severe
muscular atrophy
DISEASE
no
edema
DISEASE
clubbing
DISEASE
or
cyanosis
DISEASE
.HOSPITAL COURSE: The patient was admitted to preop andholding where he underwent narrow-field laryngectomy. Thepatient tolerated this procedure well. Please see theoperative note for details. Chest x-ray postoperativelyrevealed a tracheostomy tube in good position with no
pneumothorax
DISEASE
. The patient was transferred to the SurgicalIntensive Care Unit on the ventilator. He was placed on IVClindamycin and IV Flagyl.On postoperative day number one it was attempted to wean thepatient off the ventilator. The patient was weaned to CPAPAdmission Date: [**2127-7-10**] Discharge Date: [**2127-7-15**]Service: UROLOGY
Allergies
DISEASE
:Tylenol / AdvilAttending:[**First Name3 (LF) 6157**]Chief Complaint:
kidney stone
DISEASE
Major Surgical or Invasive Procedure:cystoscopy with retrograde placement of a ureteral stentHistory of Present Illness:HPI: This is a [**Age over 90 **]M with h/o of
prostate hyperplasia
DISEASE
s/p TURP x2presents from home c/o diffuse abd
pain
DISEASE
that radiated to theRLQ. A CTU revealed and 4mm obstructing R ureteral stone Admission Date: [**2154-7-2**] Discharge Date: [**2154-7-10**]Date of Birth: [**2096-7-25**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:Vicodin / LisinoprilAttending:[**First Name3 (LF) 1505**]Chief Complaint:
Exertional chest pain
DISEASE
Major Surgical or Invasive Procedure:s/p Aortic Valve Replacement ([**First Name8 (NamePattern2) 6158**] [**Male First Name (un) 923**] Regent Mechanical)[**2154-7-2**]History of Present Illness:57 year old female with history of
aortic stenosis
DISEASE
followed byserial echocardiogram and now symptomatic with increasedexertional
chest burning
DISEASE
Past Medical History:
Aortic Stenosis
DISEASE
Hypertension
DISEASE
Elevated cholesterolPalpitations
Gastric Esophageal reflux disease
DISEASE
Duodenal ulcer
DISEASE
Depression
DISEASE
Attention deficit disorder
DISEASE
H pyloriSocial History:Semi retired architect/professorMarried lives with spouse[**Name (NI) 1139**] - 20 pack year history quit 2 years agoEtoh deniesFamily History:Father with
PVD
DISEASE
deceased MI age 57Physical Exam:General HR 52 RR 16 146/61Skin and HEENT: unremarkableNeck supple full ROMChest CTA bilatHeart RRRAbd soft ND NT Admission Date: [**2115-7-27**] Discharge Date: [**2115-7-29**]Service: SURGERY
Allergies
DISEASE
:Penicillins / Sulfa (Sulfonamides) / MorphineAttending:[**First Name3 (LF) 371**]Chief Complaint:s/p mechanical fall with medial orbital wall fx and increased Leye intraocular pressures (46-48) as well as
hemorrhagic
DISEASE
chemosis
DISEASE
L eye L lat canthus lac lacs of R elbow and L kneeMajor Surgical or Invasive Procedure:noneHistory of Present Illness:88 year-old woman fell while using walkerAdmission Date: [**2162-3-19**] Discharge Date: [**2162-3-20**]Date of Birth: [**2085-8-29**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 99**]Chief Complaint:bright red blood per rectumMajor Surgical or Invasive Procedure:sigmoidoscopyHistory of Present Illness:76-year-old man with history of
diverticulosis prostate cancer
DISEASE
stroke
DISEASE
on
Aggrenox DM2 hypertension
DISEASE
presented with BRBPR.Patient reported having 2 episodes of
bleeding
DISEASE
with bowelmovements the night of presentation claiming that toilet bowlwas filled with bright red blood. Denies
abdominal pain
DISEASE
lightheadedness chest pain shortness of breath
DISEASE
.Patient had a colonoscopy many years ago--he doesn't rememberwhen-- which was reportedly Admission Date: [**2119-10-31**] Discharge Date: [**2119-11-5**]Date of Birth: [**2072-1-20**] Sex: MService: MEDICINE
Allergies
DISEASE
:LisinoprilAttending:[**First Name3 (LF) 562**]Chief Complaint:
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:Mr. [**Known lastname **] is a 47 year old male with
HIV( last CD4 301 [**8-7**]
DISEASE
)
ESRD
DISEASE
on PD
dilated cardiomyopathy
DISEASE
(EF 30%) who presents with
cough
DISEASE
and SOB. Patient notes being in his usual state of healthuntil Admission Date: [**2104-2-20**] Discharge Date: [**2105-3-3**]Date of Birth: [**2027-9-18**] Sex: MService:HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 6193**] is a 77 year oldRussian-speaking man with known
coronary artery disease
DISEASE
witha one year history of worsening
chest pain
DISEASE
now with unstableangina scheduled for cardiac catheterization in [**2104-10-25**] after a positive stress test. The patient elected topostpone the procedure at that time. The patient presentedto the Emergency Room on [**2-19**] with a
complaint
DISEASE
of
chest pain
DISEASE
and
shortness of breath
DISEASE
.PAST MEDICAL HISTORY: Significant for
diabetes mellitus
DISEASE
typeIIAdmission Date: [**2115-1-21**] Discharge Date: [**2115-1-23**]Service: MEDICAL ICU/[**Hospital1 212**]HISTORY OF PRESENT ILLNESS: The patient is an 83 year-oldwhite male with a history of large left sided lung mass whorecently had a biopsy who presented with mental statuschanges and
vomiting
DISEASE
followed by
hypoxemia
DISEASE
. He had a biopsyof his lung mass on [**2115-1-18**]. On the day prior toadmission the patient complained of
pain
DISEASE
at his biopsy sitewhich is controlled with Percocet. On the morning ofadmission he developed a
fever
DISEASE
to 101.7 degrees Fahrenheitrectally. His O2 sats were 90% on 2.5 liters nasal cannula.A chest x-ray revealed left upper lobe and right lower lobeinfiltrates and the patient was started on Levofloxacin forpresumed
pneumonia
DISEASE
. Later that day he gradually became morelethargic and required more
pain
DISEASE
medication. After the oneepisode of
vomiting
DISEASE
the patient's O2 sats fell to the 80s on2.5 liters per minute nasal cannula and he was 92% on 8liters of nasal cannula. He was then transferred to the [**Hospital1 1444**] for further management. Onarrival the patient required 100% nonrebreather face mask tokeep his O2 sats in the high to mid 90s. A chest x-rayrevealed left lower lobe collapse and consolidation with anadditional infiltrate around the mass and a moderate sizedleft
pleural effusion
DISEASE
. He was given a dose of Levofloxacinand Flagyl in the Emergency Department. Arterial blood gason a nonrebreather mask revealed pH at 7.2 on oxygen CO2 of80 and oxygen of 125. A trial of BIPAP was attemptedhowever the patient could not tolerate the mask. He wasthen placed back on a nonrebreather with almost identicalarterial blood gas of 7.20 79 and 125. The MICU team wasthen called to evaluate the patient.PAST MEDICAL HISTORY:1. Chronic
obstructive pulmonary disease
DISEASE
on 2 liters nasalcannula at home. Pulmonary function tests in [**2107**] showed anFEV of 0.62 FVC of 1.3 and FEV/FVC of 45%.2. Peripheral
vascular disease
DISEASE
status post right femoralpopliteal bypass graft.3. Coronary
artery disease
DISEASE
status post percutaneoustransluminal coronary angioplasty and
myocardial infarction
DISEASE
.4. Hypertension.5. Type 2 diabetes.6. Benign
prostatic hypertrophy
DISEASE
status post transurethralresection of the prostate.7. Depression.8. Essential
tremor
DISEASE
.9.
Bladder cancer
DISEASE
.10. Benign
positional vertigo
DISEASE
.11. Lung cancer metastatic to the liver. Recent biopsyperformed with biopsy results pending.ALLERGIES: Sulfa
rash
DISEASE
.MEDICATIONS ON ADMISSION: Heparin Tylenol #3 aspirinLactulose Fluoxetine Isosorbide mononitrate ImdurLisinopril Fluticasone Atrovent Albuterol Senna andColace.HOSPITAL COURSE: The [**Hospital 228**] hospital course wascomplicated by his continued
respiratory distress
DISEASE
. Thepatient continued to request no invasive measures includingno intubation no resuscitation and no chest tube placement.Essentially the patient wanted to die peacefully and not haveany invasive measures done to sustain his life. At thatpoint the patient was transferred to the MICU to the medicalfloor. He continued to have respiratory decline and waseventually unresponsive and made comfort measures only by hisfamily whose daughter [**Name (NI) 4051**] [**Name (NI) 6203**] who is his health careproxy. The patient passed on [**2115-1-23**] at around5:00 p.m. He died of
respiratory failure
DISEASE
secondary to lung
cancer
DISEASE
secondary to
pneumonia
DISEASE
. The patient's family declineda post mortem examination. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 4263**]Dictated By:[**Doctor Last Name 6204**]MEDQUIST36D: [**2115-1-24**] 10:01T: [**2115-1-24**] 10:23JOB#: [**Job Number 6205**]Admission Date: [**2112-4-11**] Discharge Date: [**2112-4-25**]Date of Birth: [**2041-7-25**] Sex: FService: GREEN [**Last Name (un) **]HISTORY OF PRESENT ILLNESS: The patient is a 70 year oldfemale who presented with a five day history of
nausea
DISEASE
and
vomiting
DISEASE
associated with
abdominal pain
DISEASE
. The patient wasunable to tolerate a liquid diet and complained of
constipation
DISEASE
on admission. The patient last had acolonoscopy in [**2110-12-17**] which demonstrated
adenomatous
DISEASE
polyps in the mid-descending colon. The patient had onesimilar episode of
nausea
DISEASE
and
vomiting
DISEASE
with
abdominal pain
DISEASE
that was peristaltic in nature one year prior to presentationwhich resolved after an enema in the emergency room. Thepatient otherwise denied
chest pain dysuria melena
DISEASE
hematochezia
DISEASE
or any other symptoms. She did complain ofoccasional
shortness of breath
DISEASE
.PAST MEDICAL HISTORY: Coronary
artery disease
DISEASE
MI.
Peripheral vascular disease
DISEASE
.
Atrial fibrillation
DISEASE
.
Osteoporosis
DISEASE
. Hyperlipidemia.
Breast cancer
DISEASE
. Asthma.
Hypothyroidism
DISEASE
. History of
UTIs
DISEASE
. Adenocarcinoma of therectum. Congestive
heart failure
DISEASE
with ejection fraction of50 percent.PAST SURGICAL HISTORY: Left mastectomy. Low anteriorresection in [**2108**]. Open reduction and internal fixation ofthe right tibia. Aortic-femoral bypass. Bilateral THR.Left femoral endarterectomy Dacron angioplasty.MEDICATIONS ON ADMISSION: Amiodarone 200 mg p.o. q.d. Imdur10 mg p.o. t.i.d. Advair one to two puffs q.12 hours p.r.n.albuterol one to two puffs q.six hours p.r.n. alendronate 5mg p.o. q.day nitrofurantoin aspirin 325 mg p.o. q.dayLopressor 25 mg p.o. q.day folic acid 1 mg p.o. q.dayvitamin B-12 100 mcg p.o. q.day multivitamin one tablet p.o.q.day.ALLERGIES: No known
drug allergies
DISEASE
.SOCIAL HISTORY: The patient had a history of a 40 pack yearsmoking history and quit five years ago.PHYSICAL EXAMINATION: On admission temperature 99.0 pulse81 blood pressure 137/76 respiratory rate 16 oxygensaturation 97 percent in room air. In general the patientwas a well-developed well-nourished Caucasian female in noacute distress. HEENT pupils equal round reactive tolight anicteric extraocular muscles intact. Neck supplemidline no
lymphadenopathy
DISEASE
or
tenderness
DISEASE
. Chest lungs wereclear to auscultation bilaterally. Cardiovascular regularrate and rhythm positive S1 S2 no murmurs rubs orgallops. Abdomen soft tender in the left lower quadrantmostly but evidence of diffuse tenderness. No masses no
organomegaly
DISEASE
. Rectal positive stool guaiac positive nomasses. Extremities warm and well perfused no
edema
DISEASE
nontender.LABORATORY DATA: On admission white blood cell count 4.4 32bands hematocrit 42.7 platelets 273. INR 1.2 PT 13.2 PTT25.9. ALT 17 AST 19 alkaline phosphatase 106 totalbilirubin 0.5. Sodium 131 potassium 4.1 chloride 91bicarb 22 BUN 28 creatinine 0.9 glucose 140. Calcium 9.7magnesium 1.7 phosphate 4.0. Lactate 1.0. KUB showed
dilated small bowel
DISEASE
with positive air fluid levels. CTangiogram previously ordered by patient's pulmonologist showedno evidence of
pulmonary embolus
DISEASE
but an enlarged gallbladder.EKG ST depressions in leads V5 to V6 biphasic T waves in V2and V3 normal sinus rhythm at 84 beats per minute with normalaxis.IMPRESSION: The patient is a 70 year old female with ahistory of
coronary artery disease atrial fibrillation
DISEASE
breast cancer asthma hypothyroidism
DISEASE
and
adenocarcinoma
DISEASE
ofthe rectum who presents with
nausea
DISEASE
and
vomiting abdominal pain
DISEASE
and the presence of air fluid levels on KUB. Theadmitting diagnosis was potential small bowel obstruction.HOSPITAL COURSE:1. FEN/GI. The patient was admitted to the surgery servicewith the admitting diagnosis of possible
small bowel
obstruction
DISEASE
. She was made NPO and an NG tube was placed andIV fluids were administered. Due to her clinical lack ofimprovement the patient was taken to the operating room on[**2112-4-12**] where she underwent exploratory laparotomy and lysisof
adhesions
DISEASE
for high grade
small bowel obstruction
DISEASE
. Thesurgery itself was uncomplicated and she had minimal bloodloss.The patient's postoperative course was complicated by
hypotension
DISEASE
post-op as well as
congestive heart failure
DISEASE
. Thepatient required about 10 liters of intravenous resuscitationimmediately post-op. She subsequently developed
congestive
heart failure
DISEASE
and
atrial fibrillation
DISEASE
which were treated withIV furosemide and IV amiodarone for rate control and sheconverted to normal sinus rhythm. She diuresed well withfurosemide but due to her persistent
respiratory distress
DISEASE
and increasing oxygen requirements she was transferred tothe MICU for further more careful monitoring.The [**Hospital 228**] hospital course was also complicated by
fever
DISEASE
which reached a maximum temperature of 101.8 on [**4-12**]. Bloodcultures were obtained and are negative to date. She alsohad
anemia
DISEASE
with hematocrit of 27 for which she received oneunit of packed red blood cells.The patient's aggressive diuresis continued. At one pointLasix was held due to episodes of
hypotension
DISEASE
. Again
hypotension
DISEASE
responded to fluids and Lasix was restartedwithout incident. The patient's oxygen was weaned down froma nonrebreather to 1 liter at the time of this dictation.Her diet was advanced slowly and by the time of discharge shewas passing flatus had
bowel movements
DISEASE
was not nauseouswas tolerating a regular diet.The patient had an echocardiogram which showed an ejectionfraction of 55 to 60 percent. There was also focal right
ventricular hypokinesis
DISEASE
with trivial
mitral regurgitation
DISEASE
.Overall it was within normal limits.The patient had repeat chest x-ray which showed intervalimprovement in her
congestive heart failure
DISEASE
.The patient's electrolytes were repleted as necessary. Her
pain
DISEASE
was well controlled with
oral pain
DISEASE
medications. She diddevelop loose stools at one point but
Clostridium difficile
DISEASE
toxin was negative.CONDITION ON DISCHARGE: Good.DISCHARGE STATUS: Rehabilitation facility ([**Hospital 100**] RehabFacility).DISCHARGE DIAGNOSES:1. Small bowel obstruction.2. Postoperative
atrial fibrillation
DISEASE
.3. Coronary
artery disease
DISEASE
.4.
Hypercholesterolemia
DISEASE
.5. Congestive
heart failure
DISEASE
.6. Asthma.DISCHARGE MEDICATIONS:1. Albuterol one to two puffs q.four to six hours p.r.n.2. Fluticasone propionate two puffs b.i.d. p.r.n.3. Advair 50 mcg one puff q.12 hours p.r.n.4. Metoprolol 12.5 mg p.o. b.i.d.5. Amiodarone 200 mg p.o. q.d.6. Bisacodyl 10 mg suppository p.r.n.7. Protonix 40 mg p.o. q.d.8. Colace 100 mg p.o. t.i.d.9. Ibuprofen 400 mg p.o. q.six hours.10. Furosemide 20 mg p.o. b.i.d.11. Zofran 4 mg q.four to six hours p.r.n.
nausea
DISEASE
.FOLLOWUP: The patient was instructed to follow up with Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in two weeks. [**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern1) 4953**] M.D. [**MD Number(1) 4954**]Dictated By:[**Name8 (MD) 6206**]MEDQUIST36D: [**2112-4-25**] 08:29T: [**2112-4-25**] 09:13JOB#: [**Job Number 6207**]cc:[**Hospital6 6208**]Admission Date: [**2148-2-3**] Discharge Date: [**2148-2-7**]Date of Birth: [**2087-6-7**] Sex: FService: SURGERY
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 598**]Chief Complaint:Pedestrian struck by motor vehicleMajor Surgical or Invasive Procedure:[**2147-2-3**]: Chest tube insertionHistory of Present Illness:60 year old female pedestrian struck at Admission Date: [**2112-9-8**] Discharge Date: [**2112-9-14**]Date of Birth: [**2041-7-25**] Sex: FService: MED
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Last Name (NamePattern1) 6209**]Chief Complaint:
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:71 yo female extensive PMHx admitted with
hypotension
DISEASE
and
hypoxia
DISEASE
most likely due to RML/RLL
pneumonia
DISEASE
. Pt in usual stateof health until night before admissin when experienced flare of
asthma
DISEASE
and no improvement on albuterol continued mild SOB
chest tightness
DISEASE
but no
cough
DISEASE
. Pt also experienced subjective
fevers
DISEASE
and
chills
DISEASE
. Remainder of ROS neg. In the ED SBP 70stransiently on dopamine and then levophedAdmission Date: [**2114-10-26**] Discharge Date: [**2114-10-30**]Date of Birth: [**2041-7-25**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:Metrogel / DesipramineAttending:[**First Name3 (LF) 5790**]Chief Complaint: Ms. [**Known lastname 6164**] is a 73-year-old womanwho had fallen several days ago and who developed
shortness
DISEASE
of breath. She was found to have a large
hemothorax
DISEASE
on chestCT.Major Surgical or Invasive Procedure:right vats evacuation of
hematoma
DISEASE
History of Present Illness:73 y/o woman tripped [**2114-10-23**] and fell onto R. head R. eye R.side and R. knee presents with R
hemothorax
DISEASE
.Past Medical History:CAD s/p MI in 94
PVD
DISEASE
(s/p aorto-fem bypass and L femoral endarterectomy)L Breast CA s/p mastectomypresumbed
diastolic disfunction
DISEASE
colon adenocarcinoma '
DISEASE
[**08**] s/p LAR with Chemo and XRTSBO s/p XLap with LOA in [**3-20**]
asthma
DISEASE
hypothyroidism
DISEASE
hyperlipidemia
DISEASE
osteoporosis
DISEASE
ORIF R tibiabilateral THR [**2110**]recurrent
UTI
DISEASE
Social History:no tobacco alcohol IVDAlives with husbandFamily History:NCPhysical Exam:general: 73 yo female w/ SOB after trip and fall.HEENT:
ecchymosis
DISEASE
over right face and orbit.chest: breath sounds decreased at right base. left clear. Admission Date: [**2117-2-6**] Discharge Date: [**2117-2-10**]Date of Birth: [**2041-7-25**] Sex: FService: SURGERY
Allergies
DISEASE
:Metrogel / Desipramine / SancturaAttending:[**Last Name (NamePattern1) 4659**]Chief Complaint:
sepsis
DISEASE
Major Surgical or Invasive Procedure:R IJ central venous line placementHistory of Present Illness:The patient is a 75-year-old female who complains ofprogressively worsening rectal and buttock
pain
DISEASE
over the past 2weeks. Upon presenting to the [**Hospital1 18**] ED today she initially hadaHR of 77 with a BP of 105/69 but quickly became
hypotensive
DISEASE
to56/40 with a heart rate of 98.
Sepsis
DISEASE
protocol was initiated. Acentral line was placed with great difficulty due tonear-complete IVC collapse. She was placed on a norepinephrinedrip and underwent a CT scan when she was somewhat stable. Thescan shows a large pre-sarcal abscess with rim enhancement andair and fat stranding tracking to a R hip prosthesis.On [**2116-12-20**] she underwent a diverting loop colostomy by Dr.[**Last Name (STitle) **] for a large
rectovaginal fistula
DISEASE
. Intra-operatively shewas noted to have stool in the rectum vaginal and presacralspace and the posterior/presacral space was cleaned out. Shewasdischarged on POD#6. It is noteworthy that prior to heroperation she did manifest
fever
DISEASE
and
hypotension
DISEASE
to SBP of 75.An echocardiogram was reassuring with an EF of 65% with trace
valvular disease
DISEASE
.She was evaluated in clinic about two weeks ago by Dr. [**Last Name (STitle) **]who was not reassured by her progress at that time. Sheappeared to be slowly declining with a pelvic choleca situationwhich was not amenable to repair due to the prior radiationdamage and poor vascular supply.Past Medical History:CAD s/p MI in 94
PVD
DISEASE
(s/p aorto-fem bypass and L femoral endarterectomy)L Breast CA s/p mastectomy in early 90's
Colon adenocarcinoma '[**
DISEASE
08**] s/p LAR with Chemo and XRTSBO s/p XLap with LOA in [**3-20**]Asthma
Hypothyroidism
DISEASE
Hyperlipidemia
DISEASE
Osteoporosis
DISEASE
ORIF R tibiaBilateral THR [**2110**]PAFSocial History:She lives in [**Location 4288**] with her husband. She is a former smokerbut quit 15 years ago. She reports drinking vodka and fruitjuice Admission Date: [**2178-10-16**] Discharge Date:Service:CHIEF COMPLAINT: Back
pain
DISEASE
.HISTORY OF PRESENT ILLNESS: The patient had beenexperiencing
intermittent back pain
DISEASE
over the past week whohas a well known history of
osteoarthritis
DISEASE
of the spine. Hewas given Percocet for
pain
DISEASE
control without improvement inhis symptomatology. He was seen in the Emergency Room on[**2178-10-16**] and at that time because of increasing
pain
DISEASE
and dropin his hematocrit from 30.0 to 20.6. The patient denies any
chest pain
DISEASE
or short of breath. He is admitted for urgentrepair of a
ruptured abdominal aortic aneurysm
DISEASE
8 cm in size.PAST MEDICAL HISTORY: Osteoarthritis T-spine compression
fracture
DISEASE
.PAST SURGICAL HISTORY: Right inguinal
hernia
DISEASE
repair.Vertebral steroid injections.The patient is a previous smoker.MEDICATIONS:1. Zantac.2. Fosamax.3. Iron.4. Percocet.The patient is not
allergic
DISEASE
to any foods or drugs. Does havea history of asbestos exposure.PHYSICAL EXAMINATION: Shows vital signs 96.1 142/86 9018 room air sat was 96% Head eyes ears nose and throatexam is unremarkable. There are no
carotid bruits
DISEASE
. Lungsare clear to auscultation. Heart is regular rate and rhythm.Abdomen is distended with bowel sounds is nontender. Thereis no bruits. Extremities have palpable femoral pulsesbilaterally without distal dorsalis pedis bilaterally. Therectal exam was guaiac negative.LABS: Hematocrit of 20.6 with a white count of 16.5 BUN 42creatinine 1.7. Potassium 4.7. Urinalysis was positive fornitrates.Chest x-ray showed bilateral
pleural effusions
DISEASE
with pleuralplaques the right greater than the left.Electrocardiogram was without acute changes. Normal sinusrhythm.The patient was taken to the operating room and underwent
abdominal aortic aneurysm
DISEASE
repair. He was then transfused 12units of packed red blood cells and also received 5 units ofFFP and two units of platelets intraoperatively. He remainedintubated was transferred to the SICU for continuedmonitoring and care. His SICU course was prolonged andcomplicated by
respiratory failure
DISEASE
. He had multiple bloodcultures drawn and urine cultures obtained because of
failure
DISEASE
to wean. His sputum cultures were on [**10-21**] negative. Hisurine culture on [**10-18**] and [**10-16**] were negative. He underwenta bronchoscopy on [**10-23**] with Endotracheal tube change at thattime. There were no blockages seen vocal cords were normaland there was mild
bronchial edema
DISEASE
on the mucosaendotracheal bronchial tree. The right IJ cortise wasconverted to a central line on [**10-25**] and required leftsubclavian line placement later that day. The patientremained intubated chest x-ray remained unremarkable exceptfor the bilateral
pleural effusions
DISEASE
and some basilar
atelectasis
DISEASE
.The patient was finally extubated on [**2178-10-28**]. Physicaltherapy was requested for evaluation. During this period inSICU the patient required TPN and tube feed support.On [**2178-10-30**] the patient passed flatus and had a bowelmovement. He was then at that time transferred to MICU forcontinued monitoring and care.On [**11-5**] the left subclavian line was changed to left IJ. Hewas begun on p.o.'s and diet advanced as tolerated. The TPNand tube feeds were discontinued after caloric intake wasevaluated.On [**2178-11-8**] the patient became
tachypneic
DISEASE
and tachycardiac.Electrocardiogram was without acute ischemic changes. Achest x-ray was unchanged. The chest CT was negative for
pulmonary embolism
DISEASE
. Abdominal CT showed distendedgallbladder. His liver function tests were elevated with anALT of 94 AST 81 Alk phos 293 total bili 6.9 Lipase 73amylase 106 lactate was 1.8 blood gases 7.38 31 99 and 13with an elevated white count of 33.0 with a T-max of 102.6.The patient required re-intubation and transfer to the SICU.Gastrointestinal was consulted. An ultrasound of thegallbladder was obtained and needle aspirate was done. Thepatient was empirically begun on Unasyn. The cultures of theblood urine sputum and gallbladder were no growth. The
Infectious Disease
DISEASE
was consulted at this time. He wasempirically started on Unasyn Vancomycin and Flagyl. CK andTroponin levels were obtained and they were flat.On [**11-10**] the patient was extubated without incident and theright subclavian line was changed. Cultures were sent to theline at this point of the dictation are no growth but notfinalized. Vancomycin was discontinued. Oxacillin was begunon [**2178-11-11**] 2 grams q 6 hours for suspected line
sepsis
DISEASE
. TheNasogastric tube was removed. His diet was advanced astolerated on [**2178-11-12**]. PICC line was placed and the centralline was discontinued. He received two units of packed cellsfor hematocrit. Oxacillin was started for the enterococcuswhich was 10000 to 100000 organisms in his urine cultureand sensitivity on [**2178-11-8**].The transfusion was for a hematocrit of 26.7 he received twounits. His post transfusion crit was 33.3.The patient continued to do well. Physical therapy continuedto work with the patient. Recommended rehabilitation andcase management was requested to screen the patientappropriate facilities.At the time of discharge the patient's wounds were clean dryand intact. He was medically stable.DISCHARGE MEDICATION:1. Albuterol multidose inhaler puffs two q 4 hours.2. Insulin sliding scale glucose of less than 60 no insulin glucoses 131 to 151 one unit 151 to 200 two units 201 to 250 4 units 251 to 300 6 units 301 to 350 8 units 351 to 400 10 units greater than 400 12 units and call.3. Heparin subcutaneously b.i.d.4. Boost with meals.5. Vioxx 25 mg q day.6. Lasix 20 mg q day.7. Lopressor 37.5 mg b.i.d.8. Albuterol Atrovent nebulizer treatments q 4 hours p.r.n.9. Oxacillin 2 grams intravenous q 4 hours for a total of two weeks.FOLLOW-UP: Patient should be seen by Dr. [**Last Name (STitle) **] in twoweeks post discharge.DISCHARGE DIAGNOSIS:1. Ruptured
abdominal aortic aneurysm
DISEASE
with repair.2. Metabolic
acidosis
DISEASE
etiology undetermined corrected.3.
Respiratory failure
DISEASE
requiring prolonged intubation extubated stable.4.
Blood loss anemia
DISEASE
transfused corrected.5. Enterococcus urinary tract infection treated. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**] M.D. [**MD Number(1) 6223**]Dictated By:[**Last Name (NamePattern1) 1479**]MEDQUIST36D: [**2178-11-15**] 16:59T: [**2178-11-15**] 16:57JOB#: [**Job Number 6224**]Admission Date: [**2107-3-3**] Discharge Date: [**2107-3-17**]Date of Birth: [**2056-9-8**] Sex: FService:ADMISSION DIAGNOSIS:
Abdominal pain
DISEASE
DISCHARGE DIAGNOSIS:1.
Mitral valve regurgitation
DISEASE
2. Congestive
heart failure
DISEASE
3. Status post mitral valve repairHISTORY OF PRESENT ILLNESS: The patient is a 50 year oldblack woman who reported sudden onset of
abdominal pain
DISEASE
approximately one week ago. Abdominal pain has been steadilyworsening and the patient reports no change in bowelsymptoms. The patient has had a decrease in appetite andsudden increase in
shortness of breath
DISEASE
. The
pain
DISEASE
isepigastric in nature and crampy. The patient was admittedfor workup of her
abdominal pain
DISEASE
.PAST MEDICAL HISTORY: 1. Morbid obesityAdmission Date: [**2193-7-13**] Discharge Date: [**2193-7-18**]Date of Birth: [**2157-7-20**] Sex: MService: MED
Allergies
DISEASE
:Phenobarbital / Valium / HaldolAttending:[**First Name3 (LF) 398**]Chief Complaint:
Constipation
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:35 yo male with mental retaration and chronic consipation (doesnot verbalize Mother takes care with him.) p/w 3 weeks historyof
constipation
DISEASE
and recent
dystonic reaction
DISEASE
to Haldol treatedwith Ativan. Two weeks prior to visit pt was
oozing
DISEASE
fecalmatter per rectum according to mother. sx of restlessnessgeneralized
pain
DISEASE
rubbing head and ears stomach is distended pt having troublewalking Pt is retarded and can not verbalize his symptoms.
Referred back to [**Hospital1
DISEASE
18**] ER. Pt has a history of severe
constipation
DISEASE
only fully dissolved with fecla disimpaction.Patient recently returned from [**State 1727**]. Mother reports BM T thisam Wed [**Name (NI) 5929**]. Giaiac Neg in ED.Past Medical History:mental retardation
seizure
DISEASE
disorder(Grand mal
seizure
DISEASE
[**Month (only) 205**] l993. He hasbeen on Dilantin since and has had no further
seizure
DISEASE
activity)
hypertension
DISEASE
history of
sinusitis
DISEASE
[**Last Name (un) 6226**]-[**Last Name (un) 6227**] diseasehistory of developmental delaySocial History:mentally retarded and lives w/ familyFamily History:n/cPhysical Exam:VSS T 100.4 Admission Date: [**2138-7-25**] Discharge Date: [**2138-9-4**]Date of Birth: [**2072-7-20**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2297**]Chief Complaint:
Respiratory Failure
DISEASE
Major Surgical or Invasive Procedure:TracheostomyIntubationR Thoracentesis (x2)Central Line PlacementPICC Line Placement
HD
DISEASE
line placementHemodialysis (CVVH)PEG PlacementHistory of Present Illness:61 year old man PMH of DM type II with recent hospitaladmission ([**5-22**]) for enterococcal
bacteremia
DISEASE
and
aortitis
DISEASE
presented to OSH on [**2138-7-22**] complaining of 6 weeks of back
pain
DISEASE
and
bowel incontinence
DISEASE
. Patient said onset of severe
back pain
DISEASE
began approximately 6 weeks ago in lower right side worse withsitting or standing. If attempted to stand he experience
pain
DISEASE
shooting up his back. He last walked approximately 6 weeks ago.The
pain
DISEASE
has been stable not worsening. He reports mildimprovement. He is now able to roll in bed. Yesterday patientwas unable to turn his head to the side. That has sinceresolved..Two weeks ago patient developed
bowel incontinence
DISEASE
. He can notsense when he is going. He has loss of stool approximately3-4x/day. Also reports decreased urine output with no leakage ordribbling. Patient feels he is dehydrated.He decided to go to the hospital when after attempting to getout of bed he felt very dizzy and Admission Date: [**2160-12-17**] Discharge Date:Date of Birth: Sex: MService:HISTORY OF PRESENT ILLNESS: This is a 54-year-old gentlemanwith past medical history significant for end stage renaldisease peritoneal dialysis times one year status post
glomerular nephritis
DISEASE
and renal transplant times three andaortic valve replacement secondary to
calcific
DISEASE
aorta whoadmission also comes in with a little bit of
back pain
DISEASE
andsome
chills
DISEASE
. She denied any localizing symptoms no
cough
DISEASE
no
chest pain
DISEASE
no
shortness of breath no abdominal pain
DISEASE
no
flank pain
DISEASE
. He did have some mild
nausea
DISEASE
earlier the day ofadmission which seemed to have resolved. He called hisprimary care physician and was told to go to the EmergencyRoom. The day prior to admission the patient had an MRA toand third finger on his right hand.PAST MEDICAL HISTORY: Included
end stage renal disease
DISEASE
status post peritoneal dialysis times one year post
glomerular nephritis renal transplant
DISEASE
times three chronic
anemia hypertension
DISEASE
aortic valve replacement secondary to
calcific aorta otitis
DISEASE
and
GI polyps
DISEASE
.MEDICATIONS: Prednisone 3.75 mg q d Atenolol 25/50RenaGel TUMS aluminum hydroxide Prilosec Coumadin 5 mgand 3 mg alternating.ALLERGIES: Captopril which gave him a
rash
DISEASE
and talcumpowder.FAMILY HISTORY: Significant for father having esophageal
carcinoma
DISEASE
. Patient denied any alcohol or drug use. Nosmoking history. Occupation: Patient is a plastic surgeonand was practicing doing his surgery two weeks prior toadmission.PHYSICAL EXAMINATION: In the Emergency Room included atemperature of 101.7 heart rate 112 blood pressure 153/112.This is a pleasant white man lying in bed appeared prettysick looking. HEENT: Pupils are equal round and reactiveto light and accommodation. Oropharynx was clear. Anictericsclera. Neck was supple no
lymphadenopathy
DISEASE
. Chest wasclear to auscultation bilaterally. Cardiovascular was tachyregular rate and rhythm grade 3/6 systolic ejection murmurheard best at the apex. GI was soft nontender nondistended normoactive bowel sounds. GU no
CVA tenderness
DISEASE
no
flank pain
DISEASE
. Musculoskeletal: Patient had right secondand third finger ischemic at the fingertips otherwise no
cyanosis
DISEASE
no
clubbing
DISEASE
no
edema
DISEASE
. Skin with no evidence ofany rashes. Neuro patient was alert oriented.LABORATORY DATA: On admission included a white count of12.6 hematocrit 29.4 platelet count 91000 Chem 7 of138/4.9 99/25 BUN and creatinine 48/13.4 glucose 91calcium 9.1 phosphorus 4.0 magnesium 1.7. Differential onthe white count was 71% polys 10% bands 14 lymphs no eosno basos. Peritoneal fluid had two white cells 19 RBC 60PMNs 30 lymphs 20 monos. Gram stain with no PMNs noorganisms. Urinalysis cannot be done because patient did notmake any urine. Chest x-ray was clear on admission.HOSPITAL COURSE: On [**12-18**] the patient had some respiratory
failure
DISEASE
and
hypotension
DISEASE
. As patient developed
fevers
DISEASE
chills
DISEASE
with no obvious source of
infection
DISEASE
but developedsome
hypoxia
DISEASE
overnight was on nasal cannula however in themorning had increased respiratory rate and decreased O2
saturations with PH of 7.16 and increasing
somnolence
DISEASE
. Thepatient had CT scan to evaluate his questionable abdominalsource however the patient was then admitted to the medicalICU because he became
hypotensive
DISEASE
in the 70's but respondedto minimal IV fluids. The patient was started on someVancomycin Gentamycin and Flagyl for his ongoing
fevers
DISEASE
. Inthe medical ICU the patient was noted to be
hypotensive
DISEASE
andalso with an increased
metabolic acidosis
DISEASE
probably secondaryto
sepsis
DISEASE
. The patient was started on some Neo-Synephrineand Levophed for aggressive blood pressure control as well assome aggressive fluid management. The patient also startedon Levofloxacin for coverage and antibiotics. The patientwas then on Levo Flagyl Gent and Vancomycin. The patientalso was found to be in DIC with an elevated PT PTT. If theplatelets were lower the patient needed to receive somefresh frozen plasma anticoagulation factors as well as someplatelets for this support. The patient had right groin lineplaced as well as a left femoral line placed and someperipheral IVs as well. Later on that evening at 4:30 p.m.on [**1-18**] the patient became bradycardic with heart rate in the30's with a low blood pressure. The patient was givenAtropine .5 mg an amp of Epi with resolving of increasedheart rate blood pressure and patient was also given Calciumand some bicarb. Then patient went into VT with the rate atabout 200 was shocked about 200-300 joules and then was backin sinus rhythm with rate of 140 with a little bit of
hypotension
DISEASE
. The patient had his electrolytes repleted. Thepatient was found to be over breathing the ventilation withhigh respiratory rates despite the sedation with Fentanyl andAtivan. Therefore patient was paralyzed to maximizeventilation. The patient was also changed off the differentpressors with Levophed and Vasopressin. The patient was thengiven hemodialysis instead of his peritoneal dialysis for thenext couple of days. The patient was continued on hisantibiotic regimen of Ceftriaxone Vancomycin Levofloxacin
Flagyl
DISEASE
as well as Vancomycin for his unknown source. Thepatient then had a pulmonary bronchoscopy to evaluate to seeif there is any bacterial
pneumonia
DISEASE
but the patient had noevidence of anything on bronchoscopy. Bronchial alveolarlavage was done which in turn was negative. The patient alsohad a TEE for further evaluation with questionable
endocarditis
DISEASE
however no
vegetations
DISEASE
were seen on thepatient's aortic valve. The patient was cultured numeroustimes in terms of his blood cultures as well as sputumcultures as well as peritoneal dialysis fluid however nosource ended up ever growing out anything.COMPLICATED MEDICAL ICU COURSE:1. ID:
Septic shock
DISEASE
. Etiology of the
septic shock
DISEASE
was notentirely clear as chest x-ray CT scans were just compatiblewith
ARDS
DISEASE
and multifocal
pneumonia
DISEASE
. However no bug evergrew out. The patient was continued on VancomycinGentamycin Levofloxacin Ceftriaxone. TEE was performed torule out
endocarditis
DISEASE
however was negative. The patientwas continued on various pressors to support his bloodpressure given the
septic
DISEASE
picture such as Levophed andVasopressin. As the patient remained in house the patientended up developing some C. diff
colitis
DISEASE
probably secondaryto all the antibiotics he was on. The patient was given a 10day course of po Vancomycin per his NG tube as well as beingcontinued on the other antibiotics. The patient had hisperitoneal dialysate fluid as well as various sputum culturesand blood cultures sent for any temperature spike that he hadhad. Nothing had ever grown out of any of these cultures.The patient was continued on Levofloxacin Flagyl VancoGentamycin for 14 day course total. The patient had all hismedications renally dosed as patient has end stage renaldisease. The patient had various tipped catheters of hiscentral lines changed over wires as well as re-sited and tipswere sent for culture however nothing ever grew out aswell. The patient had CT scan of his abdomen times two whichrevealed a left iliopsoas abscess which eventually wasdrained however no bug or any white cells were found inthat abscess. As well patient had evidence on abdominal CTscan of an enlarged gallbladder which was drained howeverjust revealed normal biliary substances with no bacteria noPMNs. The only thing that ever grew back besides the C. diff
colitis
DISEASE
was a sputum culture that was positive for MRSA on[**1-15**]. The patient had various other negative blood culturessputum cultures as stated before under the ID aspect of this.2. Renal: The patient was end
stage renal disease
DISEASE
wasstarted on hemodialysis as he first was admitted to theMedical Intensive Care Unit however eventually the patientwent over to peritoneal dialysis as he did at home. Thepatient was continued pretty much on his outpatient regimenhowever while on dialysis the patient developed some glucoseintolerance from the high Dextrose levels found in theperitoneal dialysis fluid. The patient was started on aninsulin drip and blood sugars were monitored closely whilepatient was on peritoneal dialysis requiring differentinsulin doses daily. Eventually patient was placed on an NPHdose as well as insulin being added to his peritonealdialysis fluid. Currently patient is pretty much on his ownhome dialysate as well as home dialysis schedule.3. Respiratory: Patient was ventilator dependent onadmission to medical ICU on [**12-18**]. The patient remained onthe ventilator for full support until finally extubated on[**2161-1-15**]. The patient was very much sedated from all themedications that we gave him including Fentanyl Ativan aswell as
paralysis
DISEASE
. So it took awhile to wean the patient ofthe ventilator due to the excessive sedation. Howeverpatient finally weaned on [**1-15**] while minimal Fentanyl andAtivan drips which eventually were shut off and was able tosat well on nasal cannula O2 as well as a face mask. Afterpatient was admitted to the Medical Intensive Care Unit andventilated the patient developed an ARDS type of picture andhe was vented in a way to keep his total volumes low fordecreased
lung injury
DISEASE
. The patient remained on theventilator as I stated before until [**1-15**] when he wasextubated and patient had some satting.4. GI: As stated before the patient had C. diff cultureswhich eventually were positive. The patient was started andcompleted a 14 day regimen of po Vancomycin and eventuallyhad a repeat C. diff culture which was negative. The patientalso developed evidence of some lower
GI bleed
DISEASE
as well as hehas had melenic stools as well as an upper GI bleed withpositive NG lavage. The patient had a colonoscopy done whilein house on [**1-19**] which showed some evidence of some ischemic
colitis
DISEASE
as well as a couple of polyps. The patient had someEpinephrine injected into the part of the colon which wasactively
bleeding
DISEASE
at the time. The patient's hematocritremained stable after that and evidence of the
GI bleed
DISEASE
seemed to have decreased. The patient had evidence of some
pancreatitis
DISEASE
with rising amylase and lipase levels whichprobably was attributed to his
septic
DISEASE
picture. The patientalso had a minimal elevation in his LFTs but withnormalization of his total bilirubin and his alkalinephosphatase therefore it was thought that this was due to
sepsis
DISEASE
rather than a primary source of the gallbladder at thetime until patient finally had the gallbladder drained whichrevealed that it was indeed just due to his npo status andhaving an enlarged gallbladder rather than having infectious
cholangitis
DISEASE
or such.5. Heme: Patient was admitted to the Medical Intensive CareUnit in
sepsis
DISEASE
. The patient was in a DIC type of picture.The patient required excessive platelets as well as bloodtransfusions as well as other coagulation factors for supportof his DIC picture. The patient also had to be on Heparinfor an AVR replacement which he had had done previously soPTT was monitored pretty closely.6. Cardiovascular: The patient had a history of
hypertension
DISEASE
when he came in. He was on Atenolol. Thepatient needed aggressive pressor support as well as fluidboluses to maintain his blood pressure while he was in the
septic
DISEASE
picture. The patient was on Neo-Synephrine as well asLevophed as well as some Vasopressin for support of his bloodpressure control. The patient was weaned off of all pressorson [**1-11**] and was hemodynamically stable not requiring anymorepressor support. Blood pressure at times was maintained withsome fluid boluses as patient sometimes got a little bit
hypotensive
DISEASE
while he started peritoneal dialysis. Howeverthat seemed to have resolved as we changed his peritonealdialysate to make his fluid status pretty much even.7. Fluids Electrolytes & Nutrition: The patient wasstarted on TPN while in house and after extubation patientwas on tube feeds. The patient has been tolerating tubefeeds well started on Neo-Pro for further nutrition while ontube feeds. He was started on Criticare and tolerated itwell.8. Endocrine: The patient had evidence of glucoseintolerance secondary to the high Dextrose as well as the
sepsis
DISEASE
picture as well as the chronic Prednisone thatpatient was taking at home. The patient was started as Isaid before on an insulin drip which was titrated to keephis blood sugars tightly controlled between 90 and 110however eventually patient was weaned off the insulin dripand was given NPH insulin as well as insulin and his PD fluidfor better blood glucose control. Currently patient wasgetting the insulin and the PD fluid as well as sliding scalefor control with fingersticks checked every two hours whileundergoing the peritoneal dialysate. The patient wascontinued on stress dose steroids for the chronic Prednisonehe took at home. He was started on 100 mg qid of Hydrocortand eventually was weaned down to 15 mg tid of Hydrocort andeventually 10 mg of Prednisone.9. Musculoskeletal/Neuro: The patient was paralyzed afterthe intubation as the patient got
hypotensive
DISEASE
as well aspatient was given high dose steroids. The patient afterbeing taken off the
paralysis
DISEASE
and being tailored down on thesteroids the patient continued to be extremely weak andfairly less spontaneous movements. After extubation thepatient slowly gained a little bit of strength back as theFentanyl and Ativan were wearing down as well as stronger aswhen he was having some physical therapy. The patientremained extremely weak had very little spontaneousmovements and difficulty speaking. The patient will needaggressive physical therapy to get back to his baseline aspatient is a plastic surgeon and was fully active prior tocoming into the hospital.I will update any further events that occur after thisdictation on an addendum and will summarize the ID course atthat seems to have been his major issue during thisadmission. DR.[**First Name (STitle) **][**First Name3 (LF) **] 11-647Dictated By:[**Last Name (NamePattern1) 6234**]MEDQUIST36D: [**2161-1-22**] 13:09T: [**2161-1-24**] 09:37JOB#: [**Job Number 6235**]Admission Date: [**2160-12-17**] Discharge Date:Date of Birth: [**2106-1-16**] Sex: MService:ADDENDUM:Under the neurologic aspect of his care in the MedicalIntensive Care Unit the patient was on high dose
paralytic
DISEASE
as well as some high dose steroids. The patient continued tobe lethargic with decreased movement of his upper extremitiesas well as lower extremities.The patient had a head CT which was unequivocal for anyfindings other than slight
sinusitis
DISEASE
. The patient also had amagnetic resonance scan of his head and his spine to evaluateif there was any central process causing his upper and lower
extremity weakness
DISEASE
. Both the CT scan as well as the magneticresonance scan of the head as well as the magnetic resonancescan of the neck revealed no central process that causes
extensive motor weakness
DISEASE
.Neurology was consulted and attributed this to be a criticalcare
neuropathy
DISEASE
. An
EMG
DISEASE
was also performed which onlyrevealed that it was
neuropathy
DISEASE
however the patient wasvery sedated at the time and it was not the best time toperform it because the patient was under high dose sedation.However according to neurology it was very likely to be aIntensive Care Unit
neuropathy
DISEASE
and the patient willeventually regain his strength as high dose paralytics aswell as high dose steroids as well as the stress from beingin
sepsis
DISEASE
alone will hopefully wear off and the patient willregain his strength hopefully to his full ability.The patient's mental status apparently was normalized towardsthe end of the admission as the patient was respondingappropriately with head nods as well as minimal spontaneousmovements of his upper and lower extremities. The patientwas also able to attempt to speak and was able to talk withus although be it extremely difficult for the patient due tohis weakness and was able to talk and let us know exactlywhat was bothering him.We will add more to this dictation summary as his long andextensive hospital course continues. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**] M.D. [**MD Number(1) 1212**]Dictated By:[**Last Name (NamePattern1) 6234**]MEDQUIST36D: [**2161-1-22**] 13:19T: [**2161-1-24**] 10:14JOB#: [**Job Number 6236**]Admission Date: [**2161-9-25**] Discharge Date: [**2161-10-5**]Date of Birth: [**2106-1-16**] Sex: MService: COLORECTALADMITTING DIAGNOSIS:1. End-stage
renal disease
DISEASE
.2. Adult
respiratory distress syndrome
DISEASE
.3. Severe
colitis
DISEASE
.4. Fatal
arrhythmia
DISEASE
.HISTORY OF PRESENT ILLNESS: The patient is a 54 year oldmale with
end-stage renal disease
DISEASE
secondary topost-Streptococcal
glomerular nephritis
DISEASE
and CPDD and adrenalinsufficiency who presented with two to three weeks of lower
abdominal pain
DISEASE
and was found to be
Clostridium difficile
DISEASE
positive. Upon work-up the patient showed worseningabdominal CT scan consistent with pan-colitis.The patient was initially treated with Vancomycinintravenously with p.o. Ciprofloxacin and Flagyl. On[**2161-9-28**] the patient was found to be gasping for air whileon 100% non-rebreather mask with an arterial blood gases of7.04 80 43. The patient was immediately intubated andadmitted to the Surgical Intensive Care Unit at which timethe patient was found to have
atrial fibrillation
DISEASE
with heartrate between 100 to 140. Rate was very difficult to controland Diltiazem drip was initiated.On [**2161-9-27**] the patient's heart rate remainedbetween 90 to 110 with Diltiazem drip at 10 mg per hour andblood pressure was also difficult to maintain. The patientresponded well initially to boluses with decrease in
tachycardia
DISEASE
however due to the worsening pan-colitis thepatient was taken back to the Operating Room for a subtotalcolectomy.PHYSICAL EXAMINATION: N/A.SUMMARY OF HOSPITAL COURSE: The patient is a 55 year oldmale status post subtotal colectomy and end-ileostomy for
infarcted small intestine
DISEASE
and
colitis
DISEASE
with
pseudomembranes
DISEASE
.The patient was initiated on broad-spectrum antibiotics withcultures sent. The patient's CT scan of the abdomenindicated a diffuse
thickening of terminal ileum
DISEASE
and largeintestine to the transverse colon without stranding.A repeat CT scan immediately prior to the subtotal colectomyindicated pan-colitis which progressed from prior scan but noevidence of
perforation
DISEASE
.Immediately postoperatively the patient continued to have
respiratory distress
DISEASE
requiring increased pressor support andrequired continued transfusion with seven units both of Ptwo units of packed red blood cells and four liters ofCrystalloid.Despite the continued resuscitation the patient remained
hypotensive
DISEASE
with continued
lactic acidosis
DISEASE
requiringbicarbonate replacement. The aggressive resuscitationcontinued until [**2161-10-5**] when after a longdiscussion with the family members the patient was madecomfort measures only.The patient developed a
ventricular fibrillation
DISEASE
shortlythereafter and expired later on that evening.DISCHARGE DIAGNOSES: Status post subtotal colectomy andileostomy.DISPOSITION:
Death
DISEASE
. [**Last Name (NamePattern4) 1889**] M.D. [**MD Number(1) 1890**]Dictated By:[**Name8 (MD) 6247**]MEDQUIST36D: [**2162-2-28**] 12:11T: [**2162-2-28**] 16:26JOB#: [**Job Number 6248**]Admission Date: [**2174-5-3**] Discharge Date: [**2174-6-3**]Date of Birth: [**2110-2-28**] Sex: MService: MEDICINE
Allergies
DISEASE
:CiprofloxacinAttending:[**First Name3 (LF) 2195**]Chief Complaint:found downMajor Surgical or Invasive Procedure:Left craniotomyHistory of Present Illness:In brief this is a 64 yo M with hx of
melanoma
DISEASE
s/p craniotomyand resection of metastatic
melanoma
DISEASE
in brain. He was initiallyadmitted after found down on [**5-3**]. Had multiple intraparencymal
hematomas SAH
DISEASE
SDH. Underwent resection of
tumor
DISEASE
and cystcavities on [**5-6**]. S/p craniotomy which was done on [**5-6**] he hasbeen
aphasic
DISEASE
and had ongoing
myoclonic seizures
DISEASE
. He wasmonitored on EEG and last
seizure
DISEASE
was 3 days ago thought to bein setting of
sepsis
DISEASE
and lowered sz threshhold. He is currentlyon max doses of dilantin and Keppra and being followed by neurofor AED recommendations. He was transferred to MICU formanagement of
septic shock
DISEASE
after blood cx grew enterobactercloacae (possibly spread from urine). He was on CTX butcurrently on meropenem afebrile and no leukocytosis. He has aPICC line in place for a 14-day course of meropenem. LP was donein MICU and was normal. Throughout the MICU stay he has beentachycardic with a fib and
flutter
DISEASE
intermittently on tele. On[**5-15**] he was ruled out for PE with negative CTA and LENIs. Heresponds to fluids and HR is currently in the 90s on POdiltiazem and metoprolol. [**Name (NI) **] sister is his HCP and hasrecently made him DNR/DNI she would like to discuss goals ofcare with the primary team. Neuro-oncology has been followingand he may require XRT but there has been some discussion of hiscurrent poor performance status limiting gains of furthertherapy.ROS: as in HPIPast Medical History:
HTN
DISEASE
Hypercholestolemia lung CA Asthma
Depression
DISEASE
Social History:He is divorced and lives alone. He is a hairdresser ondisablity for the past seven years. He is a heavy smoker. He hasone brother and one sister both are healthy. He has nochildren. His health care proxy is her sister [**Name (NI) **]Admission Date: [**2102-1-17**] Discharge Date: [**2102-1-31**]Service: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4111**]Chief Complaint:
Nausea distention
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Mr. [**Known lastname 6249**] is a [**Age over 90 **] year-old male with a history of
diverticulitis
DISEASE
s/p Hartmann's procedure in [**5-11**] and who mostrecently is s/p exploratory laparotomy with LOA in [**11-12**] whichhas been complicated by prolonged
ileus
DISEASE
and presented to [**Hospital1 18**]on [**2102-1-17**] for evaluation and treatment.Past Medical History:As above including: htn
diverticulitis sigmoid volvulus
DISEASE
SBOs COPD
DISEASE
PSH
DISEASE
: likely L colectomy hartmanns [**5-11**] ostomy takedown [**8-11**]internal
hernia
DISEASE
w/ SBO 1 week later s/p exlap loa repairincisional
hernia
DISEASE
repair [**4-11**]Social History:Married with four children. Former owner of restaurant. Formersmoker.Physical Exam:Alert no distressDecreased [**Last Name (un) 6250**] sounds at lung baseRRRAbd distended soft nontenderBrief Hospital Course:Mr. [**Known lastname 6249**] is a [**Age over 90 **] year-old male with a history of
diverticulitis
DISEASE
s/p Hartmann's procedure in [**5-11**] and who mostrecently is s/p exploratory laparotomy with LOA in [**11-12**] whichhas been complicated by prolonged
ileus
DISEASE
and presented to [**Hospital1 18**]on [**2102-1-17**] for evaluation and treatment. He was admitted to thesurgery service. A rectal tube was placed. On [**1-18**] Mr.[**Known lastname 6249**] was found to be in
respiratory distress
DISEASE
and wasintubated. CXR revealed
atelectasis
DISEASE
and infiltrate. A CT torsorevealed no evidence of sbo but a fluid filled sigmoid. He wascontinued on antibiotics. He was started on neostigmine. Hewas extuabated two days later and would remain stable from arespiratory standpoint. He was transferred to the floor instable condition. Success was achieved with a combination ofprokinetics and dulcolax and his bowel functioned returned. Hewas started on oral pyridostigmine and reglan. He begantolerating a regular diet and by the time of discharge he wastaking in an adequate amount of oral intake. The rectal tubewas removed. He was discharged to rehab in good condition on[**2102-1-31**] tolerating a regular diet having
bowel movements
DISEASE
andwith less
abdominal distention
DISEASE
. He should receive dulcolax for
constipation
DISEASE
or
abdominal distention
DISEASE
. A rectal tube as wellshould be placed for marked distention.Discharge Medications:1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:One (1) Inhalation Q6H (every 6 hours) as needed for
Wheezing
DISEASE
.2. Ipratropium Bromide 0.02 % Solution Sig: One (1) InhalationQ6H (every 6 hours) as needed for
dyspnea
DISEASE
.3. Heparin (Porcine) 5000 unit/mL Solution Sig: One (1)Injection [**Hospital1 **] (2 times a day).4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)Injection ASDIR (AS DIRECTED).5. Camphor-Menthol 0.5-0.5 %
Lotion
DISEASE
Sig: One (1) Appl TopicalQID (4 times a day) as needed.6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):hold for sbp Admission Date: [**2155-9-16**] Discharge Date: [**2155-9-19**]Date of Birth: [**2073-2-20**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Doctor First Name 1402**]Chief Complaint:
Ventricular tachycardia
DISEASE
Major Surgical or Invasive Procedure:-VT ablation-ICD generator changeHistory of Present Illness:This morning the patient was having breakfast when he heard a
loud banging noise
DISEASE
and dropped his cup of tea. This episode wasnot accompanied by any other symptoms. The patient denied any
chest pain
DISEASE
. His baseline does involve symptoms of
exertional
DISEASE
dyspnea
DISEASE
with moderate physical activity but no symptoms of
dyspnea
DISEASE
at rest
orthopnea
DISEASE
paroxysmal
nocturnal dyspnea
DISEASE
(heconsistently sleeps on two pillows) or lower extremity edema.He has not had any episodes of
dizziness
DISEASE
or
syncope
DISEASE
..The patient reported for a routine ICD outpatient check and wasdiscovered to be in sustained
ventricular tachycardia
DISEASE
at about160-170 beats per minute. The patient's son was told that the 4shocks in the recent pastAdmission Date: [**2121-5-10**] Discharge Date: [**2121-5-12**]Date of Birth: [**2067-11-18**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 3624**]Chief Complaint:
Hypotension
DISEASE
Major Surgical or Invasive Procedure:R IJ central line placementHistory of Present Illness:Briefly this is 53 yo M s/p DDRT in [**2111**] who was in his usalstate of health until 2 days prior to presentation when hedevelped non-bloody
diarrhea
DISEASE
and non
bloody non-bilious emesis
DISEASE
.No sick contract no travel no abnormal food exposure and norecent antibiotic exposure. He reports lightheadedness and
dizziness
DISEASE
and 2
syncopal
DISEASE
episodes..In the emergency department he was found to be
hypotensive
DISEASE
withBP 70/40 (baseline SBP Admission Date: [**2122-1-5**] Discharge Date: [**2122-1-24**]Date of Birth: [**2067-11-18**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 613**]Chief Complaint:
Right leg pain
DISEASE
and
swelling
DISEASE
Major Surgical or Invasive Procedure:Temporary IVC filter placementEsophagogastroduodenoscopycolonoscopyHistory of Present Illness:54 y.o. male with PMHx of
ESRD
DISEASE
(thought to be [**3-14**]
HTN
DISEASE
) s/pdeceased donor kidney transplant in [**2111**]
HTN
DISEASE
and
gout
DISEASE
whopresented to the ER with right leg swelling and
pain
DISEASE
x 3 days.He denies any recent injury or prolonged travel and has not hadproblems with leg
swelling
DISEASE
in the past. He additionally deniesSOB or CP. In the ED patient was evaluated and noted to have atender erythematous right LE with a right calf measuring 43cmcompared to 38 cm of the left calf. Bilateral LE dopplers wereperformed and showed a
DVT
DISEASE
in the right common femoral to thecalf veins. Given his
kidney disease
DISEASE
renal transplant wasconsulted in the ED and felt there were no active transplantissues. Patient was noted to be guaiac positive and does have ahistory of a
colonic polyp
DISEASE
found in [**2119**]. A Heparin gtt wasstarted and the patient was admitted for further management.Past Medical History:
ESRD
DISEASE
Admission Date: [**2191-4-18**] Discharge Date: [**2191-5-10**]Date of Birth: [**2112-3-14**] Sex: MService: MEDICINE
Allergies
DISEASE
:CeftriaxoneAttending:[**First Name3 (LF) 2297**]Chief Complaint:
Pneumonia
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:This is a 79 yo recently diagnosed with [**Doctor Last Name 6261**] syndrome(transformation of
CLL
DISEASE
to large B cell NHL) now s/p 3 cycles ofCHOP presents with PNA diagnosed at [**Hospital1 **] ED. The pt isnow referred from [**Hospital 478**] clinic for treatment of PNA. The ptpresented to OSH ED on [**4-13**] and was diagnosed with LLL PNA andwas given a course of levofloxacin. The pt did not take his abxas prescribed. He c/o increased SOB DOE and
cough
DISEASE
x 1 week.The pt also c/o decrease appetite over past week with 4 lb
weight loss
DISEASE
. No increase in
fatigue
DISEASE
. No f/c/s n/v d/c
abdominal pain chest pain
DISEASE
or
pain
DISEASE
with inspiration.Past Medical History:1) CAD2)
HTN
DISEASE
3)
Dyslipidemia
DISEASE
4)
PVD
DISEASE
s/p PTCA RCI/LCI/LEI stenting and fem bypass5)
Arthritis
DISEASE
6) h/o
CVA
DISEASE
while on ASA/plavix7) BPH8) Early
Parkinson's Disease
DISEASE
.Onc History:subcarinal LAD noted on bronchscopy in [**1-23**] which was negativefor malignant cells.
Referred
DISEASE
by Dr. [**First Name (STitle) 1313**] to heme onc forenlarged lower lobe lung mass. Mediastinoscopy was performed in[**11-22**] which was suggestive of atypical
chronic lymphocytic
DISEASE
leukemia
DISEASE
. Lung biopsy performed revealed a large Bcell
NHL
DISEASE
. Theprobable basis for his problem is understood to betransformation of
CLL
DISEASE
to a [**Doctor Last Name 6261**] syndrome. s/p 3 cycles ofCHOP.Lymph Node bx [**11-22**]:Immunophenotypic findings are of involvement by alambda-restricted CD5 positive B-cell lymphoproliferativedisorder. The differential diagnosis includes an atypical
chronic lymphocytic leukemia
DISEASE
(with subset loss of CD23)..CT [**2191-4-5**]:1. Unchanged size of left lower lung lobe mass measuringapproximately 7.4 cm in greatest
axial dimension
DISEASE
. This mass hasdecreased attenuation when compared with the prior exam whichmay be secondary to chemotherapy treatment and
necrosis
DISEASE
. Smallpulmonary nodules in the lower lobes bilaterally are unchanged.Social History:Quit smoking [**2150**] smoked 1.5 ppd x 20 yrs. [**12-20**] glasseswine/day. lives alone at [**Location (un) 2725**].Family History:Mother died of
CVA
DISEASE
also had h/o stomach and
intestinal cancer
DISEASE
Father died of
CVA
DISEASE
Sister died of
lung cancer
DISEASE
Physical Exam:VS: T 97.3 P 99 BP 130/68 R 20 Sat 85-88%RAGen: AAO times 3HEENT: NCAT PERRL conjunctivae anicteric/noninjected MMM OPclearNeck: JVP 7 cmCV: RRR nS1S2 no r/m/gPulm: diffuse ronchiAbd: soft
NT/ND
DISEASE
without masses or bruits NABS no palpable HSMExt: 1Admission Date: [**2145-5-25**] Discharge Date: [**2145-5-31**]Date of Birth: [**2091-12-30**] Sex: FService: [**Location (un) 259**]CHIEF COMPLAINT: Status post right middle lobe bronchusstent removal with hemoptysis/airway secretion.HISTORY OF PRESENT ILLNESS: This 53-year-old female withpast medical history significant for Stage III-B
nonsmall
cell lung cancer
DISEASE
diagnosed in fall of [**2142**] with recurrent CFactor VIII deficiency and
epilepsy
DISEASE
who presents with
hemoptysis
DISEASE
and excessive secretions status post right mainbronchus stent removal. Originally patient was diagnosedwith
nonsmall cell lung cancer
DISEASE
in fall of [**2142**] and wastreated with XRT and chemotherapy with carboplatin and Taxol.Her disease reoccurred in [**2143-5-5**] and she was againtreated with XRT with minimal response. The
lung cancer
DISEASE
hadthen progressed.On [**2145-5-3**] the patient underwent bronchoscopy (via cytologyrevealed
nonsmall cell lung cancer
DISEASE
) with stent placement inthe bronchus intermedius. Poststent CT demonstrated adequateplacement. However the patient was unable to tolerate thestent with persistent
cough
DISEASE
and increased secretions. Shepresents today for elective stent removal. The procedure wascomplicated by 150 cc of
hemoptysis
DISEASE
poststent removal whichwas controlled with suctioning and airway protection.On arrival the patient complains of
shortness of breath
DISEASE
withincreased nonbloody secretions which is improved withnebulized lidocaine. She also complains of mild anteriorright chest discomfort which is chronic and pleuritic. Shedenies any
nausea vomiting headache chills
DISEASE
.PAST MEDICAL HISTORY:1. Stage III-B (T4 M0 N0)
nonsmall cell lung cancer
DISEASE
diagnosedin fall of [**2142**] treated with carboplatin/Taxol induction withlow dose XRT. She also had a second XRT treatment in [**2143-5-5**] and had suffered some
radiation pneumonitis
DISEASE
.2.
Catanenial epilepsy
DISEASE
treated in [**2134**].3. Factor VIII deficiency.MEDICATIONS AT HOME:1. Klonopin 0.25 mg po q4h 0.5 mg po q hs.2. Estrogen 0.3 mg po q day.3. Progesterone 200 mg po q day.4. Albuterol prn.ALLERGIES: Chemical sensitivity to quinolones macrolidesaspirin nonsteroidal anti-inflammatories and penicillin.She develops hives with levofloxacin.SOCIAL HISTORY: She is married with two children. She has a30 pack year smoking history who quit in [**2142-9-4**].FAMILY HISTORY: Mother with
lung cancer
DISEASE
and
hemophilia
DISEASE
maternal grandmother with
breast cancer
DISEASE
.PHYSICAL
EXAM
DISEASE
UPON ADMISSION: Vital signs: 144/81 100% onface mask respiratory rate 34 pulse of 133 temperature96.5. Generally this is a white female in mild distressappearing anxious. HEENT: Anicteric sclerae with clear dryoropharynx. Pupils are equal round and reactive to lightand accommodation.
Extraocular movements
DISEASE
are intact. Neckis supple without
lymphadenopathy
DISEASE
. Pulmonary: Decreasedbreath sounds in the right base [**4-6**] of the way up with some
bronchial breath sounds egophony
DISEASE
and decreased tactilefremitus. The left lung is clear to auscultation.Cardiovascular: Tachycardia normal S1 S2. No murmurs orthrills noted. Abdomen is soft nontender nondistended withnormoactive bowel sounds. Extremities: No
clubbing
DISEASE
cyanosis
DISEASE
or
edema
DISEASE
noted. Neurological: Alert and orientedtimes three and moving all four extremities.LABORATORIES UPON ADMISSION: White count is 7.1 hematocrit31.7 platelets 584. Sodium 136 potassium 4 chloride 98bicarb 21 BUN 10 creatinine 0.4 glucose 144 calcium 9.1magnesium 1.5 phosphate is 3.9. Bronchial brushing showed apositive sample of
nonsmall cell lung cancer
DISEASE
cells. Pleuralfluid on [**5-3**] show reactive mesothelial cells and nomalignant cells. On [**2145-4-5**] chest CT scan status post stentshowed stent in the right upper lobe bronchus marked withnarrowing of origin in the right middle bronchus moderate
pericardial effusion
DISEASE
small partial loculated right pleuraleffusion
right middle lobe opacity
DISEASE
and diffuse
emphysema
DISEASE
.A [**2145-5-21**] chest x-ray showed moderate large right pleuraleffusion new consistent with compared with chest x-ray on[**2145-5-7**].HOSPITAL COURSE:1.
Pulmonary - Hemoptysis
DISEASE
: Patient was initially admitted tothe Intensive Care Unit to keep her saturation above 92%.Her secretions and
cough
DISEASE
were managed with Fentanyl andsaline nebulizer treatments. She did not have any episode of
hemoptysis
DISEASE
while in the Intensive Care Unit and actuallycame down from her oxygen requirement from 100% nonrebreatherto sating 90% 4-5 liters. Her hematocrit remained stable.She was called out to the floor where she was quite stableuntil the second day on the medical floor where she thenexperienced three tablespoons of
hemoptysis
DISEASE
. She was thentransferred back to the Medical Intensive Care Unit forobservation. Her hematocrit remained stable and her
hemoptysis
DISEASE
decreased in frequency from seven episodes a dayto just five episodes a day with sputum production consistentwith a rust colored
phlegm
DISEASE
. She had no frank
hemoptysis
DISEASE
while in the Medical Intensive Care Unit. She was thencalled out to the medical floor where she soon had greaterthan 150 cc
hemoptysis
DISEASE
.Cardiopulmonary resuscitation was aggressively attempted thatthe patient could not be revived. Her airway could not bemanaged with the blood that was aspirated during her episodeof
hemoptysis
DISEASE
. The code was finally called off at 2 am on[**2145-6-1**] with pronunciation of
death
DISEASE
secondary to aspirationfrom
hemoptysis
DISEASE
.In regards to her
pulmonary effusion
DISEASE
it was thought thatthere was no need for a thoracentesis at this time. If thepatient was to spike a
fever
DISEASE
the Pulmonary team wouldconsider thoracentesis however she never did spike a
fever
DISEASE
.2.
Infectious Disease
DISEASE
: The patient did have [**4-6**] bloodcultures on [**2145-5-26**] and sputum that grew out MSSA. She wasinitially treated with Vancomycin 1 gram [**Hospital1 **] and continued onVancomycin given that she might develop sensitivities toother types of antibiotics and the fact that she wastolerating Vancomycin quite well. Given that her Vancomycintrough was less than 10 her dosage was increased to 1250 mgIV bid of the Vancomycin. A transesophageal echocardiogramwas never done because the patient requested that she havesome time to recover from her
hemoptysis
DISEASE
.3.
Nonsmall cell lung cancer
DISEASE
: The patient was initiallygoing to be setup for phototherapy. However before thiscould be attempted it was felt that her
lung cancer
DISEASE
haderoded into pulmonary arteries leading to the
hemoptysis
DISEASE
which eventually led to her
death
DISEASE
.DISCHARGE DIAGNOSES:1.
Death
DISEASE
secondary to aspiration from
hemoptysis
DISEASE
from
nonsmall lung cancer
DISEASE
eroding to pulmonary arteries.2. Methicillin sensitive Staphylococcus
aureus bacteremia
DISEASE
.3.
Nonsmall cell lung cancer
DISEASE
.DATE OF DEATH: [**2145-6-1**] at 2 am. DR.[**Last Name (STitle) **][**First Name3 (LF) **] 12-AEWDictated By:[**Last Name (NamePattern1) 4270**]MEDQUIST36D: [**2145-6-1**] 14:00T: [**2145-6-7**] 08:11JOB#: [**Job Number 6263**]Admission Date: [**2162-1-8**] Discharge Date: [**2162-1-13**]Date of Birth: [**2106-7-20**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 1505**]Chief Complaint:
Chest burning
DISEASE
mild SOBMajor Surgical or Invasive Procedure:[**2162-1-8**] Three Vessel Coronary Artery Bypass Grafting utilizingleft internal mammary artery to left anterior descendingAdmission Date: [**2166-11-8**] Discharge Date: [**2166-11-12**]Date of Birth: [**2091-11-12**] Sex: FService: MEDICINE
Allergies
DISEASE
:Keflex / Augmentin / AmoxicillinAttending:[**First Name3 (LF) 348**]Chief Complaint:Respiratory DistressMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:Pt is a 74 yo F with PMH of DM COPD and hx of foot osteo s/pmultiple debridements and surgeries admitted with respiratorydistress. The pt was found at home today in bed in respiratorydistress by her family. EMS was called and she was found to havea O2 sat 60% and appeared to be
cyanotic
DISEASE
. She was given sl NTGand nebulizer and started on Bipap in the field. On arrival to[**Hospital1 18**] ED Vitals T 102.2 HR 114 BP 156/60 RR 24 100% 40 FIO2. ECGwith
sinus tachycardia
DISEASE
. CXR negative for evidence of PNA. Shewas started on Vancomycin and Levofloxacin for
fever
DISEASE
and wasgiven solu-medrol 125 X1..On arrival to the MICU the patient was in no acute distress.Answering questions appropriately. She denies
shortness of
breath or chest pain
DISEASE
. She was alert and oriented to place andtime. Her family reports that she has increased her tobaccousage over the past week secondary to R
hip pain
DISEASE
. She was foundby her husband and daughter to be
gagging
DISEASE
with minimalrespiratory effort and appeared to have a blue-tinged color.Past Medical History:COPD/Asthma
Hypertension
DISEASE
Diabetes Type II
DISEASE
Peripheral neuropathy
DISEASE
History of MRSA osteomyelitis right footMRSA bacteremia [**6-18**].[**Doctor First Name **]: Bilateral
cataracts
DISEASE
debridement of right foot
osteomyelitis
DISEASE
x3Social History:Lives with husband smokes 2 ppd x 50 years has recently beenunder stress and admits to increasing her smoking to 3 ppd. OccETOH lives in [**Location 686**].Family History:Noncontributory.Physical Exam:ADMISSION
EXAM
DISEASE
:VS: T:98.7 R:18 Sat:95% on Bipap 10/8 BP:162/59 HR:89GEN: NAD well nourishedHEENT: PERRLA NCATNeck: no LADCV: s1/s2 no murmur pulses presentPULM:
wheezes and rhonchi
DISEASE
throughoutABD: soft NTND BS Admission Date: [**2169-8-16**] Discharge Date: [**2169-8-21**]Date of Birth: [**2091-11-12**] Sex: FService: MEDICINE
Allergies
DISEASE
:Keflex / Augmentin / AmoxicillinAttending:[**First Name3 (LF) 3556**]Chief Complaint:
Tachycardia
DISEASE
Major Surgical or Invasive Procedure:Need for non-invasive ventilation and MICU stay.History of Present Illness:77F with h/o
COPD
DISEASE
and recent admit mid-[**Month (only) **] for afib w/rvrdischarged on coumadin and diltiazem BIBA from home after VNAnoted her to be tachycardic and with labored breathing at homethis AM. Received dilt bolus by EMS and started on dilt gtt w/oimprovement in her heart rate. Pt had
dementia
DISEASE
but had nocomplaints.
Endorsed chronic cough
DISEASE
. Denied cp or sob.In the ED she was triggered for
tachycardia
DISEASE
with HR 150 andcontinued on a dilt gtt. HRs improved to the low 100s prior totransfer to the floor. CXR showed mild pulm
edema
DISEASE
with noevidence of
pneumonia
DISEASE
. She received IVF andCeftriaxone/Azithromycin. She was also noted to be
febrile
DISEASE
to102.8 UA was sent and blood and urine cultures were drawn andTylenol was given. Cr was noted to be 1.4 with lowest previousvalue of 1.1. ABG performed at 1200 was 7.34/45/220. Familynoted patient to become increasingly somnolent around 1400.On the floor the patient remained somnolent. Repeat ABG at 1700was 7.24/60/68. Per family at bedside patient is alert andawake at baseline. Given
somnolence
DISEASE
and
hypercarbia
DISEASE
and DNIstatus the decision was made to transfer the patient to theMICU. Prior to transfer she received 20mg IV furosemide withminimal output and Foley was placed.Review of systems: Unobtainable [**3-15**] patient's
somnolence
DISEASE
.Past Medical History:-Hyperthyroidism dx [**7-/2169**]-Atrial Fibrillation dx [**7-/2169**]-
Dementia
DISEASE
on aricept-
DM2
DISEASE
A1C 6.6 in [**3-/2169**]-
COPD
DISEASE
not on O2
- Gait abnormality [**3-15**] MRSA osteomyelitis with 3 surgicaldebridements- HLD-
Diabetic nephropathy
DISEASE
-
Hypertension
DISEASE
- s/p MRSA bacteremia in [**6-17**]- bilateral
cataract
DISEASE
surgerySocial History:-Tobacco history: current smoking [**2-12**] ppd history of 60 yearsat same amount (Admission Date: [**2145-9-7**] Discharge Date: [**2145-9-10**]Date of Birth: [**2101-10-20**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2901**]Chief Complaint:
Chest pain
DISEASE
Major Surgical or Invasive Procedure:Cardiac catheterization with one stent placed.History of Present Illness:43 y/o male with h/o
HTN
DISEASE
who developed SSCP nonradiatingassociated with arm/feet tingling around 12:30PM. He felt asimilar
pain
DISEASE
1 month ago after being involved in a fight andbeing punched in the chest. No past history of DOE
orthopnea
DISEASE
or PND. The patient states that he was driving and developedSSCP and he pulled over and called the ambulance. He was takento [**Hospital3 **] and his EKG revealed STE in anterolateralleads. He was given ASA nitro gtt morphine heparin IVlopressor 10 mg NS plavix 600 lipitor 80 and KCl 40. CXRnormal. He was transferred urgently to [**Hospital1 18**] for cath..[**Hospital1 18**] cath revealed normal hemodynamics 99%
LAD lesion
DISEASE
with
thrombus
DISEASE
s/p thrombectomy. No distal embolization. Normal flow..The patient came to the CCU on nitro gtt. He still c/o CP withno improvement after cath. No SOB or diapharesis.Past Medical History:PMH:
HTN
DISEASE
.
PSH
DISEASE
:NoneSocial History:The patient is currently on parole for unclear reasons. He iscurrently unemployed. He lives at home with his mom and sister.[**Name (NI) **] admits to recent (Admission Date: [**2121-3-31**] Discharge Date: [**2121-4-4**]Date of Birth: [**2054-10-31**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1505**]Chief Complaint:
Exertional chest pain
DISEASE
Major Surgical or Invasive Procedure:[**2121-3-31**] - Coronary artery bypass grafting x3: Left internalmammary artery to left anterior descending artery saphenousvein graft to the diagonal saphenous vein graft to theposterior descending artery.History of Present Illness:This 66 year old man has a history of
hypertension
DISEASE
hyperlipidemia
DISEASE
and
obesity
DISEASE
. He has been followed in the [**Month/Day/Year 2200**]clinic for quite some time. Over the summer the patient noticedseveral episodes of bilateral shoulder discomfort while walkingup a slight incline on the golf course. These episodes wouldresolve quickly with rest and then he would be able to continueon with the rest of his game without symptoms.Several weeks ago the patient noticed similar bilateral shoulderdiscomfort after walking only 100 feet. He did not experienceany
chest discomfort shortness of breath
DISEASE
or other associatedsymptoms and again after several minutes of rest his discomfortresolved.He sought consultation with Dr. [**Last Name (STitle) 2201**] who referred him forstress testing. He exercised 8.25 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocolreaching 79% of his maximum predicted heart rate. At peakexercise there was diffuse 2.0-3.0 ST segment
depression
DISEASE
in theinferior leads and 1.0-2.0 mm
depression
DISEASE
in leads I and V3-V6.The rhythm was sinus with APBAdmission Date: [**2193-8-29**] Discharge Date: [**2193-9-16**]Date of Birth: [**2156-6-6**] Sex: FService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 6088**]Chief Complaint:Leg and
back pain
DISEASE
Major Surgical or Invasive Procedure:1. Left L4-L5 Microdiscectomy2. Exploratory laparotomy with primary repair of inferior vena
cava injury
DISEASE
and Dacron interposition graft repair of rightcommon iliac artery transection.3. Primary abdominal wall closure with placement of retentionsutures and Ethicon wound bridges.History of Present Illness:(Per medical record)Ms. [**Known lastname **] has had low back
pain
DISEASE
for the past several months thathas been stable. However in [**Month (only) 216**] she developed acute onset ofsevere
pain
DISEASE
in her L leg from the buttock region down the legand all the way to the end of her foot. There is also a sense of
numbness
DISEASE
. She tried epidural steroid injections without muchrelief.Past Medical History:
Gastroparesis
DISEASE
Psoriasis
DISEASE
Anxiety
DISEASE
Social History:Married. She works as a lawyer and has to travel for work.Family History:NoncontributoryPhysical Exam:On pre-op exam:General: pleasant appears uncomfortable with walking thoughcanwalk from exam room to waiting room and bathroomAdmission Date: [**2137-12-10**] Discharge Date: [**2137-12-17**]Date of Birth: [**2077-8-2**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:Iodine-131 / EpinephrineAttending:[**First Name3 (LF) 1283**]Chief Complaint:
Dyspnea
DISEASE
on ExertionMajor Surgical or Invasive Procedure:Minimally Invasive Mitral Valve Repair with 30mm [**Doctor Last Name 405**] Bandon [**2137-12-10**]History of Present Illness:60 y/o female with h/o mitral vlave prolapse for 40 yrs. Has hadincreased
dyspnea
DISEASE
on exertion this year with an episode of
congestive heart failure
DISEASE
[**9-16**]. Recent echo showed 4Admission Date: [**2182-3-26**] Discharge Date: [**2182-3-29**]Date of Birth: [**2118-9-5**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 3531**]Chief Complaint:
Shortness of breath / n / v / diarrhea
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:63M with history of
asthma
DISEASE
possible
ILD DM
DISEASE
presenting fromhome with
shortness of breath
DISEASE
. He has been troubled by
flares
DISEASE
of
shortness of breath cough
DISEASE
and feeling of
phlegm
DISEASE
in his chestfor 9 months. Episodes at times also associated with feelingfeverish without documented elevated temps and sweats. In PCP'soffice also noted to have
hypertension
DISEASE
and
tachycardia
DISEASE
. Hadcardiac stress testing trhough PCP which was normal. Theseepisodes generally last two to three days and go away withincreasing prednisone. He has been off and on prednisonethroughout these months (up to 30-40 mg daily). One month agowas on 5 mg but has been gradually increasing steadily up to 25mg two days ago. Today took 15 mg. He was able to exerciseyesterday walking 30 minutes on the treadmill. Last nightdeveloped repeated episodes of
diarrhea
DISEASE
as well as
nausea
DISEASE
andmalaise. Breahting seemed to be worse this AM so went to ED. Noabdominal or
chest pain
DISEASE
.
Endorses orthopnea
DISEASE
and worsening ofchest congestions/phlegm feeling when supine. Has pitting
edema
DISEASE
which comes and goes he notes improving with exercise. Has notnoted significant change in sugars at home. No sick contacts.Did receive both flu vaccines this year..In the ED initial vs were: T98.3 133 143/85 28 99% on NRBAdmission Date: [**2117-11-7**] Discharge Date: [**2117-11-20**]Date of Birth: [**2065-2-7**] Sex: FService: NEUROLOGY
Allergies
DISEASE
:AspirinAttending:[**First Name3 (LF) 5018**]Chief Complaint:
Left leg weakness
DISEASE
Major Surgical or Invasive Procedure:Spinal Tap.Cerebral Angiogram x 2.History of Present Illness:52yo RH F h/o smoking until recently and multiple recent EDvisits for
headache
DISEASE
(LP negative for
meningitis SAH
DISEASE
) and seenin neurology clinic with normal motor exam as recently as [**11-4**]by Dr. [**First Name (STitle) 6817**] who prescribed fioricet for combinationmigraine/tension
headache
DISEASE
. She began taking it on Friday twodays ago and per her husband she was too drowsy anddisinhibited. He has not given it to her since. Her behavior hasremained odd since then and her family present at my interviewsays she has been overly jovial for the past few days.Her
headache
DISEASE
though has ceased apart from a Admission Date: [**2187-2-22**] Discharge Date: [**2187-2-28**]Service: MEDICINE
Allergies
DISEASE
:Vicodin / Penicillins / CompazineAttending:[**First Name3 (LF) 689**]Chief Complaint:Altered mental status.Major Surgical or Invasive Procedure:None.History of Present Illness:[**Age over 90 **] year-old female who presents from a rehabilitation facilityafter one week of altered mental status. At baseline the patienthas been alert but confused and agitated worse at nightAdmission Date: [**2148-5-28**] Discharge Date: [**2148-6-3**]Date of Birth: [**2071-7-22**] Sex: MService: NeurosurgeryHISTORY OF PRESENT ILLNESS: This is a right-handed77-year-old Chinese-speaking man with
dementia
DISEASE
who presentswith left lower extremity weakness two days after
unwitnessed
DISEASE
fall at home. The patient fell on Saturday afternoon. As heis normally home alone all day no one saw him and the wifefound him on the floor with his head on the recliner when shearrived home in the afternoon. The patient aroused easilyand was in his usual state of health until Sunday when he hadsudden profound
weakness of the left lower extremity
DISEASE
whilewalking. The wife stated that she Admission Date: [**2148-5-28**] Discharge Date: [**2148-6-3**]Date of Birth: [**2071-7-22**] Sex: MService:HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 77 year oldChinese speaking male who presented to the [**Hospital1 346**] Emergency Department with left lowerextremity weakness. The
weakness
DISEASE
occurred following a falltwo days prior. The patient is a right handed Chinesespeaking male with baseline
dementia
DISEASE
. On presentation hehad left
lower extremity weakness
DISEASE
following the
unwitnessed
DISEASE
fall at home. By patient's family report he fell onSaturday afternoon having been home alone all day and wasfound later that afternoon by his wife. She managed toarouse him and move him to a recliner but no further actionwas taken. Following the fall the patient was in his usualstate of health until the following evening on Sunday whenby family's report had had a sudden and profound weakness ofthe left lower extremity while walking. The wife is said tohave carried the patient back to his bed and the EMS wasactivated.On presentation to the Emergency Department the patient waslethargic with
confusion
DISEASE
beyond his normal baseline
dementia
DISEASE
.Through a translator he is oriented to place and recognizesface although he can be difficult to arouse at times.By family report there was no noticeable change in visual orspeech patterns and the patient appears to comprehend them.They do however report that he has had difficulty movingfood to his face.MEDICATIONS: The patient presented to the EmergencyDepartment on no chronic medications.PHYSICAL EXAMINATION: On presentation to the EmergencyDepartment vital signs are a blood pressure of 153/78Admission Date: [**2149-12-10**] Discharge Date: [**2149-12-15**]Date of Birth: [**2071-7-22**] Sex: MService: NEUROLOGY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 618**]Chief Complaint:right sided weaknessMajor Surgical or Invasive Procedure:CTsSwallow evaluationHistory of Present Illness:This is a 78 yo Cantonese speaking right handed man with ahistory of
vascular dementia stroke
DISEASE
with left sided weakness
HTN
DISEASE
h/o right SDH s/p evacuation who was in his usual state ofhealth until this morning. He walked to the bathroom and didnot come out for 20 minutes. His wife got worried and walked into find him curled up on the bathroom floor. He saidAdmission Date: [**2108-3-11**] Discharge Date: [**2108-3-12**]Date of Birth: [**2039-6-15**] Sex: MService: MICUCHIEF COMPLAINT: Dyspnea acute renal failure.HISTORY OF PRESENT ILLNESS: A 68-year-old ophthalmologistwith no significant past medical history who presents todaywith diffuse
muscle pain
DISEASE
and
dyspnea
DISEASE
on exertion times sixdays. Symptoms started when patient awoke six days prior toadmission with lumbar lower back pain. Patient states thatinitially the
pain
DISEASE
was similar to lumbar back
pain
DISEASE
in thepast however he usually notices this type of
pain
DISEASE
at theend of the day rather than first thing in the morning.Throughout the day his lower back
pain
DISEASE
worsened and patientbegan to note diffuse
myalgias
DISEASE
. Upon getting home from workthat evening he reports that the
pain
DISEASE
and
myalgias
DISEASE
were sosevere that he was unable to walk. The
weakness
DISEASE
has worsenedthroughout the course of the week and patient has beennonambulatory.His
dyspnea
DISEASE
on exertion began around the same time as the
muscle weakness
DISEASE
and prior to being unable to walk he wasonly able to do three steps before he became tachypneic. Hedoes not report any PND or
orthopnea
DISEASE
.The patient has also recently traveled to [**State 108**]approximately 10 days ago. While he was in [**State 108**] he hadan
acute diarrheal illness
DISEASE
which was described as
watery
DISEASE
andnonbloody. This resolved spontaneously and was self limited.He was unclear if this was associated with
fevers
DISEASE
.Five days prior to admission he again had recurrence ofsymptoms and his
diarrhea
DISEASE
in addition to above symptoms of
myalgias
DISEASE
and
weakness
DISEASE
. His original episode of
diarrhea
DISEASE
wasthought to be secondary to eating out at a restaurant withCuban cuisine and possible beef exposure. He does notbelieve he had any fresh water exposure and he was notswimming in any pools.On presentation to the Emergency Department he was noted tobe in moderate
respiratory distress
DISEASE
with respiratory rates inthe 30s and tachycardic with heart rates in the 100s. He wasplaced on nonrebreather face mask with initial oxygensaturation 88 percent which improved to 95 percent on 3liters without any intervention. Initial ABG showed7.33/21/134 on unknown amount of oxygen. He received 2liters of intravenous normal saline while in the EmergencyDepartment and had development of
bibasilar rales
DISEASE
. He didnot have any change in his oxygen saturation while lyingsupine.On review of systems patient complains of mild
oliguria
DISEASE
which he reports usually going 10 times per day whichdecreased to one time per day over the last six days. Henoted brown urine starting approximately four days ago. Hehas not had any
dysuria
DISEASE
or
hematuria
DISEASE
as far as he knows. Healso reports a sore throat with a question of
dysarthria
DISEASE
atthe onset of symptoms five to six days ago. He has had a
headache
DISEASE
and some blurry vision. The blurry vision wasapproximately two days prior to admission and lasted about 24hours. One day prior to admission he believes he also had anepisode of
diplopia
DISEASE
which lasted approximately six hours.He has not had any
abdominal pain nausea vomiting
DISEASE
chest
pain
DISEASE
or
palpitations
DISEASE
. Of note he and his wife who is alsoa physician noted that his thighs were mottled.PAST MEDICAL HISTORY:1. GERD.2.
Raynaud
DISEASE
's phenomenon.3.
Adenomatous polyps
DISEASE
x2 resected per colonoscopy in [**2105**].4.
Osteopenia
DISEASE
.5. Status post inguinal
hernia
DISEASE
repair.6.
Hyperlipidemia
DISEASE
.7. History of lower
back pain
DISEASE
.MEDICATIONS AT HOME:1. Aspirin 81 q.d.2. Lipitor 20 mg q.d. which has been a stable dose over the last six to seven years.3. Prilosec 20 q.d.4. Aleve two tablets q.d. prn however patient has been taking approximately four tablets per day since the onset of symptoms six days ago.5. Feldene 20 mg p.o. q.d.ALLERGIES:1. Mice dander causes
anaphylactic reaction
DISEASE
.2. Mussels (seafood) causes GI upset however other shellfish are okay.FAMILY MEDICAL HISTORY: Mother with [**Name (NI) 2481**]. Fatherdied at age 89 years old of
prostate cancer
DISEASE
.SOCIAL HISTORY: Patient is an ophthalmologist/researcher inthe area. He is married. His wife is also a physician. [**Name10 (NameIs) **]denies any tobacco use. He drinks approximately one glass ofwine per day. He has three children most of whom live inthe area.Vital signs in the Emergency Department: Temperature 94.6blood pressure 129/90 which increased to 145/75 after 2liters of intravenous fluid heart rate went from 105 to 95respiratory rate 20s oxygen saturation 89 percentile onrebreather face mask which improved to 95 percent on 3liters nasal cannula.In general patient was in mild
respiratory distress
DISEASE
however he was able to speak in full sentences. There wasno accessory muscle use. HEENT exam: Pupils are equalround and reactive. Sclerae were anicteric. Extraocularmuscles are intact. Mucous membranes were moist. Hisoropharynx was clear. He was normocephalic atraumatic.Neck was supple without any jugular venous distention orthyromegaly. Chest demonstrated bilateral
basilar rales
DISEASE
without any wheezes. Cardiovascular: Regular rate nomurmurs rubs or gallops were appreciated. Abdomen wassoft nontender nondistended liver span percussed toapproximately 3-4 cm above costal margin. There was no
splenomegaly
DISEASE
. There is a negative [**Doctor Last Name 515**] sign. On backexam he had no midline spinal tenderness to palpation. Hehad no CVA tenderness bilaterally. Extremities demonstratedtwo plus peripheral pulses. There is trace bilateral
edema
DISEASE
.Skin exam: He had no rashes however there is evidence oflivido reticularis on bilateral thighs. On neurologic examhe was alert and oriented times four with cranial nerves IIthrough XII intact. Deep tendon reflexes were symmetric.Motor strength was effort dependent however he had 3-4/5
weakness
DISEASE
in his bilateral hip flexors knee extensors kneeflexion with intact strength bilateral plantar flexiondorsiflexion. His upper extremities were 4 plus bilaterally.He had a negative
Babinski
DISEASE
. His sensation was intact tolight touch bilateral upper and lower extremities.LABORATORY VALUES ON PRESENTATION: White blood cells 6.5hemoglobin 15.5 hematocrit 46.6 MCV 91 67 percentneutrophils 11 percent bands 8 percent lymphocytes 9percent monocytes. PT 14.7 PTT 29.8 INR of 1.4.Urinalysis showed large blood nitrite positive 100 proteintrace ketones negative for leukocytes negative for RBCsnegative WBCs few bacteria. Sodium was 140 potassium 3.5chloride 97 bicarb 13 BUN 72 creatinine 4.0 which is upfrom a baseline of 1.0 glucose 200 anion gap was elevatedat 30. ALT was 96 AST 164 CK 1654 alkaline phosphatase310 total bilirubin 5.2 direct bilirubin 3.8. Lipase was20. Troponin was less than 0.01. Calcium 9.8 phosphorus3.3 magnesium 2.8 albumin 3.3. Serum and urine tox wereboth negative.DIAGNOSTIC IMAGING:1. Chest x-ray showed linear
atelectasis
DISEASE
at the left base with a right lower lobe nodule.2. CT head was negative for acute pathology.3. Abdominal ultrasound showed normal liver portal vein patent right kidney 11.7 cm with 1.7 cm simple
cyst left
kidney
DISEASE
was 10.8 cm. No
hydronephrosis
DISEASE
and no
ascites
DISEASE
were present.4. EKG showed a
sinus tachycardia
DISEASE
rate 112 P-R of 150 normal axis T-wave inversions in III and F unchanged when compared with EKG dated [**2104-5-29**].IMPRESSION: A 68-year-old gentleman with no significant pastmedical history who presents with six days of lower back
pain myalgias
DISEASE
with remote history of
diarrheal illness
DISEASE
andpossible
fevers
DISEASE
at home. While in the Emergency Departmentidentified to have mild
respiratory distress
DISEASE
which improvedwithout significant intervention as well as
acute renal
failure
DISEASE
and elevated CK. Also noted to be hypothermic with aleft shift.HOSPITAL COURSE: Patient was admitted to the MedicalIntensive Care Unit given his
acute renal failure
DISEASE
and
respiratory distress
DISEASE
. He arrived in the Medical IntensiveCare Unit approximately 6 p.m. and he was noted to have coldand
clammy extremities
DISEASE
and was now on 6 liters of oxygen pernasal cannula. Over the next two hours the patientexhibited worsening
tachypnea
DISEASE
and altered mental status. Hewas noted to have worsening
slurring of his speech
DISEASE
as well.Neurology evaluated the patient approximately one hour afterbeing admitted to the Intensive Care Unit and although wasnot able to provide a coherent history at that pointprovided a good exam which was felt to be nonfocal exceptfor mild
tongue weakness
DISEASE
.Around 8 p.m. patient's condition had deteriorated enoughthat he was extremely
delirious
DISEASE
and his respiratory rate hadincreased to approximately 40 and he was taking short andshallow breaths. He was intubated at that point without anycomplications.After intubation an arterial blood gas was performed whichshowed a pH of 7.14 pCO2 of 36 and a lactate of 8.0. Givenhis worsening clinical condition he was started on empiricantibiotics at that point for presumed blood-born
infection
DISEASE
.Initial antibiotics were broad spectrum and included ZosynLevaquin doxycycline Vancomycin Flagyl.After intubation a left subclavian line was attemptedhowever was unsuccessful. A left internal jugular centralvenous catheter was placed without complications. Followupchest x-ray after central line placement showed a moderatesized
pneumothorax
DISEASE
on the left which was decompressed with achest tube placed by Cardiothoracic Surgery.Around midnight that evening approximately six hours afteradmission to the Intensive Care Unit patient's bloodpressure had progressively fallen and now requiredintravenous pressors. He was initially started on Levophedand eventually Vasopressin followed by Neo-Synephrine wereadded. Laboratory values returned with values consistentwith DIC.Likewise his respiratory status declined throughout theevening and cisastracurium was used for
paralysis
DISEASE
. ARDS Netventilation strategy was employed however he was verydifficult to oxygenate throughout the evening. Serial bloodgases showed progressive worsening of his
acidosis
DISEASE
and by 10a.m. the next morning 16 hours after admission his bloodgas showed a pH of 6.92 and a lactate of 11.8. He had beenpreviously on a bicarb drip throughout the evening with noapparent effect.His potassium continued to rise throughout a few short hoursin the Intensive Care Unit and reached a level of 9.1 thefollowing morning at 11 a.m. The Nephrology team which hadbeen following him from the night before given his acute
renal failure
DISEASE
were contact[**Name (NI) **] early in the morning and a CVVHwas initiated. Around the time of initiation of CVVHpatient was noted to have a wide complex tachycardia and waseventually found to have evidence of complete
heart block
DISEASE
.Blood pressures despite maximum dose of three vasopressivemedications remained with the systolics in the 80s to 90s andheart rate in the 50s to 60s.A discussion was had with his wife who felt thatresuscitation would not be consistent with patient's wishesand he expired at 2:30 p.m. secondary to
cardiac arrest
DISEASE
.Blood cultures drawn from time of admission in the EmergencyDepartment later grew out methicillin-sensitive Staph aureusin four blood culture bottles. Further investigation anddiscussion with wife revealed that patient had a dentalprocedure approximately three weeks prior to admission. Itis unclear this was the source of his
bacteremia
DISEASE
or whetherthere was some infectious process which was acquired whilehe was on [**State 108**] a week and a half prior to admission.After discussion with his wife an autopsy was performed(which report is not available at this time) which wasconsistent with
septic
DISEASE
emboli to multiple organs includinghis kidneys. This was the most likely cause of his acute
renal failure
DISEASE
. There is also evidence of mitral valveinvolvement/endocarditis.DIAGNOSIS AT TIME OF DEATH:1. Methicillin-sensitive Staphylococcus aureus high grade
bacteremia
DISEASE
.2.
Endocarditis
DISEASE
.3.
Septic
DISEASE
embolic involvement of bilateral kidneys.4. DIC.5. Acute
respiratory distress syndrome
DISEASE
.6.
Metabolic acidosis
DISEASE
.7.
Hyperkalemia
DISEASE
secondary to
acute renal failure
DISEASE
.8.
Myositis
DISEASE
.9.
Respiratory failure
DISEASE
requiring intubation.10. Left tension
pneumothorax
DISEASE
. DR.[**Last Name (STitle) **][**First Name3 (LF) **] 12-697Dictated By:[**Last Name (NamePattern1) 6829**]MEDQUIST36D: [**2108-5-9**] 15:16:34T: [**2108-5-10**] 09:00:23Job#: [**Job Number 6830**]Admission Date: [**2112-1-18**] Discharge Date: [**2112-1-30**]Date of Birth: Sex:Service: [**Doctor Last Name 1181**]HISTORY OF PRESENT ILLNESS: This is an 86 year-old womanfrom [**Hospital3 **] Center where she was foundminimally responsive
cyanotic
DISEASE
diaphoretic and
tachypneic
DISEASE
with an O2 sat between 34 and 54% on 6 liter per minuteoxygen mask. She was brought to the Emergency Departmentwhere she was initially verbal and complained of some upperback
pain
DISEASE
and some
shortness of breath
DISEASE
. Her vital signs inthe Emergency Department were a blood pressure of 162/77heart rate 70 respirations 40 and her O2 sat was 93% on anonrebreather mask. It was 100% on norebreather mask. Shewas initially given 40 mg of intravenous Lasix times one inthe Emergency Department but then became
hypotensive
DISEASE
with ablood pressure of 79/47. She required a Dopamine drip. TheDopamine was weaned off and then restarted later as the bloodpressure fell yet again. Dopamine was later stopped and aneo drip was started which was later weaned off.The patient was admitted to the [**Doctor Last Name **] firm on the [**2112-1-18**]. She was treated with Levofloxacin and Flagylfor a
urinary tract infection
DISEASE
as well as possible aspiration
pneumonia
DISEASE
. She had a swallow study on the [**2112-1-19**] which she described as a
borderline dysphagia
DISEASE
and wasmade NPO but later the patient was inadvertently fed icecream by a patient. The patient was later found to have adrop in O2 sats down to 70% and required intubation transferto the Medical Intensive Care Unit. Suctioning at that timewas positive for melted ice cream. The patient was extubatedon the [**1-21**] but then felt distressed believed tobe mechanical
restrictive lung disease
DISEASE
. The patient hasnoted kyphosis scoliosis as well as
congestive heart failure
DISEASE
and
pneumonia
DISEASE
and required BiPAP at night and face maskduring the day. On the [**1-27**] the patient's nephewdecided to change the patient's status to DNR/DNI and comfortmeasures only and the patient was transferred back to the[**Doctor Last Name **] firm on the [**2112-1-28**].PAST MEDICAL HISTORY: Congestive heart failure acute renalfailure
atrial fibrillation
DISEASE
coronary
artery disease
DISEASE
hypertension
DISEASE
and a history of
scoliosis
DISEASE
and
kyphosis
DISEASE
.ALLERGIES: Intolerant of ace inhibitors.MEDICATIONS ON TRANSFER:1. Metoprolol 25 b.i.d.2. Losartan 75 mg daily.3. Multivitamin.4. Admission Date: [**2147-11-17**] Discharge Date: [**2147-12-5**]Date of Birth: [**2092-11-28**] Sex: FService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1**]Chief Complaint:
headache
DISEASE
and
neck stiffness
DISEASE
Major Surgical or Invasive Procedure:central line placed arterial line placedHistory of Present Illness:54 year old female with recent diagnosis of
ulcerative colitis
DISEASE
on 6-mercaptopurine prednisone 40-60 mg daily who presentswith a new onset of
headache
DISEASE
and
neck stiffness
DISEASE
. The patient isin distress rigoring and has
aphasia
DISEASE
and only limited historyis obtained. She reports that she was awaken 1AM the morning of[**2147-11-16**] with a
headache
DISEASE
which she describes as bandlike. Shestates that
headaches
DISEASE
are unusual for her. She denies photo- or
phonophobia
DISEASE
. She did have
neck stiffness
DISEASE
. On arrival to the EDat 5:33PM she was afebrile with a temp of
96.5
DISEASE
however shelater spiked with temp to 104.4 (rectal) HR 91 BP 112/54 RR24 O2 sat 100 %. Head CT was done and relealved attenuationwithin the subcortical white matter of the right medial frontallobe. LP was performed showing opening pressure 24 cm H2O WBC of316 Protein 152 glucose 16. She was given Vancomycin 1 gm IVCeftriaxone 2 gm IV Acyclovir 800 mg IV Ambesone 183 IVAmpicillin 2 gm IV q 4 Morphine 2-4 mg Q 4-6 Tylenol 1 gm Decadron 10 mg IV. The patient was evaluated by Neuro in theED..Of note the patient was recently diagnosed with
UC
DISEASE
and wasstarted on 6MP and a prednisone taper along with steroid enemasfor
UC
DISEASE
treatment. She was on Bactrim in past but stopped takingit for unclear reasons and unclear how long ago..Past Medical History:
chronic back pain
DISEASE
MRI negative
osteopenia
DISEASE
- fosamax d/c by
PcP
DISEASE
leg pain/parasthesiash/o
hiatal hernia
DISEASE
Social History:No tob Etoh. Patient lives alone in a 2 family home w/ afriend. She is an administrative assistantFamily History:brother w/
ulcerative proctitis
DISEASE
mother w/ severe
arthritis
DISEASE
father w/ h/o
colon polyps
DISEASE
and
GERD
DISEASE
Physical Exam:VS: 101.4 Admission Date: [**2176-4-22**] Discharge Date: [**2176-4-27**]Date of Birth: [**2118-8-24**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Shellfish DerivedAttending:[**First Name3 (LF) 1505**]Chief Complaint:
Dyspnea
DISEASE
on exertionMajor Surgical or Invasive Procedure:Coronary Artery Bypass x 3 (LIMA-LAD SVG-OM SVG-LPDA) [**2176-4-22**]History of Present Illness:57 year old male has a history of
hypertension hyperlipidemia
DISEASE
and insulin dependent
diabetes
DISEASE
. He has been fairly sedentaryover the past year and recently began to notice that he washaving
dyspnea
DISEASE
with activities that he previously could dowithout problems including climbing a flight of stairs orwalking up a slight incline. At times this has been associatedwith mild left sided chest discomfort. Recent stress echorevealed
ischemia
DISEASE
c/w three
vessel disease
DISEASE
or
LM disease
DISEASE
. He wasreferred for cardiac catheterization to further evaluate. He wasfound to have
multivessel disease
DISEASE
and is now being referred tocardiac surgery for revascularization.Past Medical History:
Coronary Artery Disease
DISEASE
s/p Coronary artery Bypass x 3PMH:
Hypertension
DISEASE
Hyperlipidemia
DISEASE
Insulin dependent
diabetes
DISEASE
Hx of
bladder cancer
DISEASE
s/p laser surgery/cauterizations/p Cholecystectomy
Umbilical hernia
DISEASE
Common bile duct stone
DISEASE
s/p ERCP with sphincterotomy [**2175-3-20**]Social History:Lives with:WifeOccupation:consultant for school systemsTobacco:quit 27 years agoETOH: 1 drink per weekFamily History:Father had a
stroke
DISEASE
while having a cardiaccatheterization and CABGPhysical Exam:Pulse:51 Resp:16 O2 sat: 99/RaB/P Right:162/77 Left:158/66Height:5'6Admission Date: [**2169-3-29**] Discharge Date: [**2169-3-31**]Service: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1384**]Chief Complaint:
infected left AV
DISEASE
graftMajor Surgical or Invasive Procedure:excision of
infected left AV graft [**2169-3-29**]
DISEASE
History of Present Illness:89 yo male who presented with
chills
DISEASE
at dialysis. He was notedto have a
fever
DISEASE
to 102 at that time. While at dialysis he wasnoted to have a ulceration over his left AV graft site with
bleeding
DISEASE
. He was transferred to [**Hospital1 18**] for further evaluationand work-up of a likely
infected left AV
DISEASE
graft.Past Medical History:CKD-- stage IV disease baseline Admission Date: [**2126-3-11**] Discharge Date: [**2126-3-18**]Date of Birth: [**2077-3-10**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 2736**]Chief Complaint:
Shortness of breath
DISEASE
Major Surgical or Invasive Procedure:Cardiac catheterizationInternal cardiac defibrillator placementHistory of Present Illness:This is a 49 year-old male with a history of
HBV hepatitis
DISEASE
onentecavir hypercholesterolemia family history of prematureCAD who presents with leg
swelling
DISEASE
and progressive SOB..Worked up in late [**2125-12-10**] for week or so of
cough
DISEASE
told hehad
pneumonia
DISEASE
by CXR received 5 days of azyhtromycin w/o anyimprovement in his
cough
DISEASE
. Got second CXR around [**12-24**]findings had not cleared got another course of 5 daysAzithromycin which he finished 7 days prior to presentationagain w/o improvement in
cough
DISEASE
. During this period except for
cough
DISEASE
complained of
exertional dyspnea
DISEASE
which has progressedrapidly over the past week from 20 stairs to
dyspnea
DISEASE
at rest.Admits to
orthopnea
DISEASE
two or more pillows describes paroxysmal
cough
DISEASE
at night but not PND. Noticed 11 lb
weight gain
DISEASE
over pasttwo months. No
nocturia
DISEASE
.
Denies chest pain
DISEASE
. Two days prior toadmission had CT chest which showed diffuse bilateral
ground-glass infiltrates
DISEASE
consistent with
infectious
DISEASE
processmost likely atypical or
viral pneumonia
DISEASE
as well as bilateral
pleural effusions
DISEASE
. On day prior to admission noticed
swelling
DISEASE
on right foot followed later by left foot swelling. Saw his PCPwho sent him to the ER.. Does not recall recent
febrile illness
DISEASE
. Believes all hissymptoms started after Admission Date: [**2167-4-11**] Discharge Date: [**2167-4-19**]Date of Birth: [**2124-2-10**] Sex: MService: MEDICINE
Allergies
DISEASE
:CompazineAttending:[**First Name3 (LF) 905**]Chief Complaint:Leg crampsMajor Surgical or Invasive Procedure:Lumbar punctureHistory of Present Illness:43 yo M with history of
rhabdomyolysis
DISEASE
related to mitochondriald/o comes w/
cramping
DISEASE
in legs. Pt reports he's been feelingsomewhat unwell since 2 days ago when he
nausea
DISEASE
after eatingchicken panini from [**Company **]. However his symptom resolvedby the end of the day. No diarrhea/abdominal pain/fevers or
chills
DISEASE
. Yesterday he was moving boxes because he's moving to adifferent apt and felt tired and took a nap. After taking a naphe woke up with
calf muscle cramping
DISEASE
and checked urine myoglobinat home which was positive. He then came to the ED. Otherwisehe denies any
chest pain
DISEASE
sob
cough diarrhea abdominal pain
DISEASE
or
constipation
DISEASE
. He reports some HA and
nasal congestion
DISEASE
but novision changes stiff
neck neck pain
DISEASE
or
rhinorrhea
DISEASE
..In the Emergency Department his CK was noted to be in 50000sand received 1L NS. 1L of bicarb was started. Initially forclose monitor of urine output hourly and 'lytes in the settingof aggressive IVF there was a consideration for MICU admission.However MICU attending did not feel that he warranted MICUadmission thus floor admission was decided. However from the[**Name (NI) **] pt went to MICU. Upon arrival to MICU pt's VS was 98.3144/90 102 11 99% on
RA
DISEASE
. Upon hearing that pt's moving againto CC7 again pt became upset and tachycardic to 120-130s and
hypertensive
DISEASE
to 182/105. Currently pt's BP 144/98 HR 94 16sat 98% on
RA
DISEASE
. Pt had uop of 500cc of
tea-colored
DISEASE
urine while inMICU. While in MICU pt finished 1L bicarb and received 2 L ofNS. 4th NS is running currently. Pt is refusing foley.Past Medical History:1.
Mitochondrial myopathy
DISEASE
with recurrent rhabdomyolysisAdmission Date: [**2104-8-21**] Discharge Date: [**2104-8-26**]Service: MEDICALHISTORY OF PRESENT ILLNESS: This is a 78 year old woman witha history of severe
chronic obstructive pulmonary disease
DISEASE
ulcerative colitis
DISEASE
status post ileostomy in [**2097**] aorticstenosis status post valvuloplasty in [**2097**] and then aorticvalve replacement with a porcine aortic valve in [**2098**] and aleft below the knee amputation in [**2065**] who has had one weekof
cough
DISEASE
and sputum production that was treated with Levaquinand Flagyl.Two days prior to admission the patient developed
nausea
DISEASE
and
vomiting
DISEASE
and stopped taking her
Flagyl
DISEASE
but still had
nausea
DISEASE
.She stopped being able to eat well and had some respiratorydistress and had
diarrhea
DISEASE
. She was sent to the EmergencyDepartment for evaluation. She denied any
chest pain
DISEASE
deniedany blood in the
diarrhea
DISEASE
denied any blood in her
vomit
DISEASE
denied
fever chills
DISEASE
.PHYSICAL EXAMINATION: On arrival in the EmergencyDepartment the patient's examination revealed she was anuncomfortable dyspneic woman on oxygen via nasal cannula whohad to pause while speaking secondary to her
dyspnea
DISEASE
. Shewas afebrile. Her blood pressure was 116/60 with a pulse of86 respiratory rate 20s with oxygen saturation of 95% inroom air. Head eyes ears nose and throat - She wasnormocephalic and atraumatic with no
icterus
DISEASE
. Her mucousmembranes were
dry
DISEASE
. She had no
jugular venous distention
DISEASE
.Her chest had basilar crackles bilaterally diffuselydecreased breath sounds. The heart was regular. She had aIII/VI
midsystolic murmur
DISEASE
. Her abdomen was obese softnontender no
hepatosplenomegaly
DISEASE
. The ileostomy bag was inplace. Her extremities revealed status post left below theknee amputation. Her right lower extremity was cool withchronic
erythema
DISEASE
and
venous stasis
DISEASE
changes and trace edema.LABORATORY DATA: On admission white count 13.9 hematocrit42.5 platelets 308000. INR 2.1. Chem7 revealed a sodium of136 potassium 5.7 chloride 111 bicarbonate 6 blood ureanitrogen 120 creatinine 3.0 glucose 110. A troponin wasless than 0.3. Urinalysis had 30 protein specific gravityof 1.016 three white cells two red cells and a fewbacteria. ALT was 8 AST 20 alkaline phosphatase 102 totalbilirubin 0.4 amylase 111 CK 53.Her chest x-ray showed no
congestive heart failure
DISEASE
and no
pneumonia
DISEASE
. Arterial blood gases at that time revealed pH7.21 pCO2 22 pO2 153.Electrocardiogram showed sinus rhythm at 90 beats per minute.Q wave in III aVF and V2 1.[**Street Address(2) 2811**]
depressions
DISEASE
inII V3 through V6. T wave inversions in I II aVL V4through V6 and biphasic in V3.HOSPITAL COURSE: She was admitted to the Medical IntensiveCare Unit for correction of her
metabolic acidosis
DISEASE
and acute
renal failure
DISEASE
and for ruling out
acute myocardial infarction
DISEASE
.1. Metabolic
acidosis
DISEASE
- She was given three amps ofbicarbonate in one liter of fluid. She had blood culturesdrawn. She was treated with oxygen. Calcium phosphorus andmagnesium levels were drawn and found to be low. She wasrepleted with those intravenously and her
acidosis
DISEASE
respondedso that on the day of transfer to the floor her bicarbonatewas 19 and she was able to tolerate p.o.2. Acute
renal failure
DISEASE
- She had a creatinine of 3.0 whenher baseline is 1.1. This responded well to intravenousfluid hydration so that on the day of transfer to the floorher creatinine was 1.8 and on the day of discharge from thehospital her creatinine was 1.3.It was thought that both
metabolic acidosis
DISEASE
and the acute
renal failure
DISEASE
were secondary to severe volume depletion from
diarrhea
DISEASE
and decreased p.o. intake. She has responded wellto intravenous rehydration and repletion of her electrolytes.3. Rule out
myocardial infarction
DISEASE
- Serial CKs were donewhich were negative. Her troponin was always less than 0.3.Despite the changes on the electrocardiogram she was foundnot to have had a
myocardial infarction
DISEASE
. It was thought thatthese changes were secondary to some
ischemia
DISEASE
probablyinduced by the volume depletion.4. Respiratory - She began to have some increasing
shortness
DISEASE
of breath on the day of transfer to the floor and stated thatat home she takes Albuterol nebulizer twice a day. Thesewere started on the floor and her breathing improved. Shecontinued on her normal respiratory medications inhalers andwas continued on b.i.d. nebulizers.5. Gastrointestinal - The patient presented with
nausea
DISEASE
vomiting diarrhea
DISEASE
and decreased p.o. intake. Over herhospital stay the
diarrhea
DISEASE
decreased and her stools becamemore formed. She was able to tolerate p.o. and hydrateherself and replete her electrolytes through p.o. Amylase andlipase were within normal limits throughout her hospitalstay.6. Infectious disease - The patient was diagnosed with
pneumonia
DISEASE
prior to admission and stopped her antibioticsduring her illness. No consolidation was seen on chest x-raybut it was decided to treat her with Levaquin and Flagyl.Flagyl was discontinued two days prior to discharge and shewill be continued on Levaquin for a total of ten days andwill stop her course on [**2104-9-1**]. Her blood cultures havebeen negative throughout as has a urine culture and she hasbeen afebrile since her transfer from the Medical IntensiveCare Unit.7. Hematology - Her INR was 2.1 on admission and it wassubsequently checked and found to be 1.9. Her liver functiontests were normal and it was felt that this was due toVitamin K depletion from poor nutrition. She was givenVitamin K p.o. for three days and her INR will be checkedagain as an outpatient.She will follow-up with her regular primary care physicianwhen she gets home.CONDITION ON DISCHARGE: Stable.DISCHARGE STATUS: She will be discharged to a rehabilitationfacility for further assistance with her activities of dailyliving respiratory status and her p.o. repletion.MEDICATIONS ON DISCHARGE:1. Albuterol and Atrovent nebulizers b.i.d.2. Atrovent MDI two puffs b.i.d.3. Vanceril MDI four puffs b.i.d.4. Humibid 600 mg p.o. b.i.d.5. Zantac 150 mg p.o. q.d.6. Isordil 10 mg p.o. t.i.d.7. Metoprolol 25 mg p.o. b.i.d.8. Levofloxacin 250 mg p.o. q.d. to finish on [**2104-9-1**].9. Heparin 5000 units subcutaneous q.d.10. Magnesium Oxide 420 mg p.o. t.i.d.11. Elavil 10 mg p.o. q.h.s. p.r.n.12. Calcium Carbonate one gram p.o. q.d.DISCHARGE DIAGNOSES:1. Chronic
obstructive pulmonary disease
DISEASE
.2. Ulcerative colitis status post ileostomy.3. Left below the knee amputation.4. Aortic stenosis status post porcine aortic valve replacement.5. Acute
renal failure
DISEASE
which is resolving. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 4263**]Dictated By:[**Last Name (NamePattern1) 6857**]MEDQUIST36D: [**2104-8-25**] 18:28T: [**2104-8-25**] 19:36JOB#: [**Job Number 6858**]Admission Date: [**2104-11-19**] Discharge Date:Service: [**Hospital1 139**]CHIEF COMPLAINT: Dehydration nausea vomiting and increasedostomy output.HISTORY OF PRESENT ILLNESS: The patient is a 78-year-oldfemale with history of
ulcerative colitis
DISEASE
status postileostomy in [**2087**] with severe
COPD
DISEASE
and a past admission forsevere
diarrhea
DISEASE
which led to
acute renal failure
DISEASE
who was inher usual state of health until 4-5 days prior to admissionwhen a VNA nurse noted increased output from her ostomy. Shealso was complaining of decreased po intake and post tussive
vomiting
DISEASE
at that time. Dr. [**Last Name (STitle) **] went to the patient'shouse on the day of admission and felt she should come to theEmergency Room for evaluation. She was also stating that shehad a slight increase in
shortness of breath
DISEASE
above baseline.In the Emergency Room she was
orthostatic
DISEASE
but afebrile andwas found to have
acute renal failure
DISEASE
with a BUN of 71creatinine up to 3.8 and a potassium of 6.6. ABG at thattime showed PH of 7.18 PCO2 31 and a PO2 of 114. EKG showedpeaked T waves. She was given bicarbonate and Albuterol nebsand hydrated with four liters of normal saline. She then wastransferred to the MICU for further care.PAST MEDICAL HISTORY: 1)
Ulcerative colitis
DISEASE
status postileostomy in [**2097**]. 2) Left BKA. 3) Aortic stenosis statuspost porcine valve replacement. 4) Cardiac catheterizationin [**3-6**] showed no evidence of
coronary artery disease
DISEASE
. 5)History of
acute renal failure
DISEASE
secondary to
dehydration
DISEASE
. 6)
Chronic obstructive pulmonary disease
DISEASE
with the most recentPFTs on [**2104-7-15**] showing an FVC of 54% predicted value andFEV1 of 24% predicted value and an FEV1 to FVC ratio of 45%.Patient's O2 sat is 91% at baseline on room air. 7)Perioperative MI in [**2097**] with persistent Q's in leads 2 3and AVF.ALLERGIES: Patient is
allergic
DISEASE
to Penicillin CodeineDemerol Procardia and Aspirin.MEDICATIONS: On admission Albuterol and Atrovent nebsAtenolol 25 mg po bid Vanceril MDI 4 puffs [**Hospital1 **] Zantac 150mg po q d Isordil 10 mg po tid Elavil 10 mg po q h.s. prnand a Multivitamin po q d.FAMILY HISTORY: The patient's daughter and her grandchildrenhave a history of
asthma
DISEASE
. She also has a daughter with
emphysema
DISEASE
.SOCIAL HISTORY: The patient currently lives alone. She hasnine children. She uses a wheelchair as well as a prosthesisto ambulate. She is a retired customer service analyst at[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 15 years ago. She has a 30 pack year smokinghistory. She quit approximately 10 years ago. She deniesany alcohol use.PHYSICAL EXAMINATION: Temperature 95.5 heart rate 85 bloodpressure 120/70 respiratory rate 25 pulse ox 99% on twoliters. In general the patient is an elderly female who is
tachypneic
DISEASE
at rest. HEENT: Revealed dry mucus membranespupils are equal round and reactive to light extraocularmovements intact. Conjunctiva are pink and non injected.The sclera are anicteric. The neck has no JVD. There was no
lymphadenopathy
DISEASE
. The carotids are 2Admission Date: [**2106-9-17**] Discharge Date: [**2106-9-23**]Service: MICUHISTORY OF PRESENT ILLNESS: Eighty-year-old female withhistory of
end-stage COPD
DISEASE
aortic valve replacement andnursing home residency brought to Emergency Room from nursinghome after complaining of increased chest pressure andunresponsive with nitroglycerin and increasing shortness ofbreath with a productive
cough
DISEASE
of white sputum. The patienthas chronic
chest pain
DISEASE
but usually responds tonitroglycerin. The patient has
chronic shortness of breath
DISEASE
with
cough
DISEASE
but more so since [**9-15**] at which point shewas seen by her PCP and started on levofloxacin.The
shortness of breath
DISEASE
increased with chest pressure sincethat point and she called for help because she thought shewas having a heart attack. In the Emergency Room thepatient had chest pressure and EKG showed evidence of an old
inferior MI
DISEASE
and rate related ST-T wave changes. The patientalso had increased blood pressure up to 220/100 with a heartrate of 116. The patient was started on nitroglycerin dripgiven Lasix 40 mg IV x1 multiple albuterol and Atroventnebulizers Solu-Medrol 125 mg IV x1 and Zestril 20 mg p.o.x1 in the ED.The patient had an ABG showing a pH of 7.17 a CO2 of 75 andan oxygen of 96 on nasal cannula and was started on BiPAP atthat point. The VBG on BiPAP was a pH of 7.23 CO2 64 andoxygen 172. Patient was then switched to 1 liter/minutenasal cannula and had an ABG of 7.25 58 and 74.Patient was observed to be in
respiratory distress
DISEASE
with
tachycardia
DISEASE
and the decision was made to restart BiPAP andobserve in the MICU.PAST MEDICAL HISTORY:1.
Ulcerative colitis
DISEASE
status post total colectomy in [**2087**].2.
COPD
DISEASE
: Chronic productive
cough chronic
DISEASE
shortness ofbreath chronic 2 liters nasal cannula O2 at baseline.3. Aortic valve replacement in '[**99**] porcine valve.4. Status post left below the knee amputation.5. MI.6. Upper
GI bleeding
DISEASE
.7.
Hypertension
DISEASE
.ALLERGIES:1. Procardia.2. Demerol.3. Penicillin.4. Codeine.5. Diltiazem.MEDICATIONS:1. Levofloxacin 500 mg p.o. q.d.2. Atenolol 50 mg p.o. q.d.3. Imdur 30 mg p.o. q.d.4. Ativan.5. Zestril 20 mg p.o. q.d.6. Claritin 10 mg p.o. q.d.7. Multivitamin.8. Protonix 40 mg p.o. q.d.9. Albuterol.10. Tylenol.11. Guaituss.12. Ambien.13. Aspirin 81 mg p.o. q.d.14. Flovent.15. Flonase.16. Serevent.17. Tums.18. Vitamin C.19. Ocean spray.PHYSICAL
EXAM
DISEASE
: Vital signs: Temperature 98.4 pulse 103blood pressure 130/52 respirations are 22 and 97%saturation on 4 liters/minute nasal cannula. In generalelderly female sitting up in bed pursed-lip breathing withuse of accessory muscles able to say short sentences alertand oriented times three. Head: Pupils are equal roundand reactive to light.
Extraocular movements
DISEASE
are intact.Oropharynx is clear. Dry mucosal membranes. Neck: JVD to10 cm no
bruits
DISEASE
. Cardiovascular: 3/6 systolic murmur withloud S1 at left upper sternal border regular rate andrhythm. Pulmonary: Decreased breath sounds [**4-6**] of the wayup bilaterally. Decreased
fremitus
DISEASE
bilaterally poor airmovement diffusely. Abdomen is soft nondistended andnontender. Positive bowel sounds. Positive ostomy bag withgas and dark green stool. Extremities: Status post leftbelow the knee amputation right heel in soft bootie. No
clubbing cyanosis
DISEASE
or
edema
DISEASE
.LABORATORIES: White count 14.7 with 81% neutrophilshematocrit 36.3 platelets 338. Coags were normal. Chem-7unremarkable. No anion gap. Urinalysis remarkable only for500 of protein. Patient was cycled for cardiac enzymes witha peak CK of 108 peak MB of 11 and troponin of 0.07.INITIAL IMPRESSION: Eighty-year-old female with end-stage
COPD
DISEASE
status post aortic valve replacement with
acute COPD
DISEASE
exacerbation and slight troponin elevation.HOSPITAL COURSE:
COPD
DISEASE
flare: The patient was maintained on a regimen of IVsteroids antibiotics frequent nebulizer treatments andchest PT and was observed in the MICU. The patient wasnoted to desaturate while not on BiPAP and retained CO2 andwas thus placed on intermittent BiPAP for support. Thepatient did not tolerate BiPAP well needing benzodiazepinesand occasional Haldol for sedation.The patient's respiratory status did improve so that thepatient was able to tolerate longer periods off BiPAP in theMICU and at that point she communicated to us that she nolonger wished to be place back on BiPAP and that she wishedto be made DNR/DNI comfort measures only. Her family waspresent for this decision and agreed. The patient at thatpoint the patient did not have BiPAP placed back on quicklydesaturated over the course of the day and expired.DISCHARGE DIAGNOSIS: Chronic
obstructive pulmonary disease
DISEASE
exacerbation.DISCHARGE CONDITION: Deceased. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 3795**]Dictated By:[**Name8 (MD) 6867**]MEDQUIST36D: [**2106-11-15**] 13:50T: [**2106-11-16**] 05:24JOB#: [**Job Number 6868**]Admission Date: [**2181-8-26**] Discharge Date: [**2181-8-29**]Date of Birth: [**2106-9-20**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2485**]Chief Complaint:
atrial fibrillation
DISEASE
and
hypotension
DISEASE
Major Surgical or Invasive Procedure:Cardioversion for unstable
atrial fibrillation
DISEASE
PICC placementHistory of Present Illness:74 Russian speaking male w/ history of
dementia depression
DISEASE
remote CAD afib s/p pacer now being admitted for increased
lethargy obtundation fever atrial fibrillation
DISEASE
and
hypotension
DISEASE
64/30 and
tachypnea
DISEASE
32-34..On review of the notes from [**Hospital 100**] rehab patient was lethargicsince [**2181-8-18**]. Olanzapine namenda and depakote stopped. His BPhad been 80-90/40-50 and P90s. On day of admission he spiked
fever
DISEASE
to 103 w/ AF w/ RVR and more
hypotension
DISEASE
. His [**Month/Day/Year 802**] wascalled and the decision was to admit him..On arrival to the ED his vital signs were T102.6 P180 BP64/30.Due to unknown code status at the time cardioversion wasattempted twice w/ 50 and 100J but to no avail. He was given 5LNS. He was also started on vanco/levo/flagyl. Later phone callto NH claims that he is DNR/DNI.On arrival to the ICU phone calls were made to [**Hospital 100**] rehabPCP([**Doctor First Name **] O/[**Location (un) **]) brother(HCP) and Nice([**Doctor First Name **] who claimsto be legal guardian. [**Name (NI) **] Rehab claims that he is DNR/DNI.Brother deferred all decision making to [**Doctor First Name **]. [**Doctor First Name **] claims to belegal guardian and wants to patient to be full code regardlessof situation. PCP did not call back at the time of admission.Past Medical History:1.
Atrial fibrillation
DISEASE
s/p pacemaker placement notanticoagulated [**3-1**] med non-adherence and fall risk. EP hadapparently evaluated his pacer which was thought to befunctional. Rate control was noted to be difficult given pt's
agitation
DISEASE
and often refusal/non-compliance w/ po agents.2. Dementia/personolity
disorder
DISEASE
as above frequently requiredchemical/mechanical restraintAdmission Date: [**2198-5-22**] Discharge Date: [**2198-5-27**]Date of Birth: [**2149-8-20**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1505**]Chief Complaint:
Chest pain
DISEASE
Major Surgical or Invasive Procedure:[**2198-5-22**] - CABGx4 (Left internal mammary -Admission Date: [**2130-12-14**] Discharge Date: [**2130-12-16**]Date of Birth: [**2057-1-13**] Sex: MService: MEDICINE
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 2932**]Chief Complaint:transient
hypotension
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:73 year old male with a history of
Type II diabetes CAD
DISEASE
s/pCABG
PVD
DISEASE
who presented to the [**Hospital1 18**] ED with
fever
DISEASE
and
weakness
DISEASE
. Patient reports that he was in his USOH until 1 night PTA whenhis son noted that his Admission Date: [**2154-4-30**] Discharge Date: [**2154-5-3**]Date of Birth: [**2092-11-28**] Sex: FService: MEDICINE
Allergies
DISEASE
:PercocetAttending:[**First Name3 (LF) 12**]Chief Complaint:
fever chills rigors
DISEASE
Major Surgical or Invasive Procedure:Arterial line placementHistory of Present Illness:61F w/ sign PMH for
UC
DISEASE
s/p
colectomy Stage II breast cancer
DISEASE
presented on day 13 of second cycle of chemotherapy with
fever
DISEASE
to 100.6 at home w/ severe
rigors
DISEASE
. She took two Ibuprofen athome and then went to onc clinic today where she was thenreferred to the ED for admission. She stated that for the pasttwo days she has noticed an increasing amount of stool output inher ostomy bag but denies abdominal discomfort or blood in herstool. She has had
nausea
DISEASE
but similar to how she has felt in thepast with chemo. She also mentioned that she recently cut herfinger in the garden on Sunday which is now red and slightlytender to the touch. She otherwise denies any
vomiting rash
DISEASE
rhinorrhea dysuria cough
DISEASE
SOB or abdominal discomfort. Shedenies any recent travel or sick contacts as well..In the ED inital vitals were Temp: 101 Admission Date: [**2117-9-12**] Discharge Date: [**2117-9-13**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:coffee ground
emesis
DISEASE
Major Surgical or Invasive Procedure:placement of R femoral Cordis resuscitation lineHistory of Present Illness:87 yo F with multiple medical problems who presents with coffeeground
emesis
DISEASE
from [**Hospital **] rehab..In the ED the patient had NG lavage that showed 200cc coffeeground
emesis
DISEASE
. Additionally the patient received 5 L NS and 2Uof PRBCs. Additionally she was given vancomycin flagyl andlevofloxacin for concern of
infection
DISEASE
. CXR showed possible freeair and surgery was contact[**Name (NI) **]. However it was confirmed thatthe family does not want surgery and thus the patient did nothave a formal [**Doctor First Name **] consult. BPs were briefly low in the ED andthe patient was started on levophed. However after furtherdiscussions with the family it was determined that the familywould like to direct the care more towards comfort and thelevofed was stopped..Upon arrival to the MICU the patient appeared to be in
pain
DISEASE
.After extensive family discussion they decided that the patientshould not be intubated and would not be a candidate forsurgery. Additionally they would like to keep the patientcomfortable.Past Medical History:1.
Diabetes
DISEASE
2.
HTN
DISEASE
3.
Hypercholesterolemia
DISEASE
4.
Arthritis
DISEASE
5.
Hypothyroid
DISEASE
6. S/p nephrectomy for renal cell ca done in 94 at BU7. MRegurgitation8.
Chronic abdominal pain
DISEASE
9. H/o
pancreatitis
DISEASE
10. pancreas divisum11.
hiatal hernia
DISEASE
repair12. left colectomy [**3-12**] [**Location (un) 6553**] b 2 colon cancer with neg nodes13. ccySocial History:No tob no etoh no narcotics lives in [**Hospital1 **] House. Threedaughters currently seeking healthcare proxy.Family History:NCPhysical Exam:VS: T 96.8 Hr 63 BP 119/93 RR 20 02 93% 3L--Admission Date: [**2155-10-1**] Discharge Date: [**2155-10-24**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4232**]Chief Complaint:
Dyspnea
DISEASE
Major Surgical or Invasive Procedure:EGDParacentesisHistory of Present Illness:83 y.o. male with h/o
CHF
DISEASE
EF Admission Date: [**2123-3-26**] Discharge Date: [**2123-3-29**]Date of Birth: [**2064-4-28**] Sex: MService: Coronary Care UnitHISTORY OF PRESENT ILLNESS: Patient is a 58-year-old manwith history of
coronary artery disease
DISEASE
status post inferior
myocardial infarction
DISEASE
[**2113-4-28**] with stent to the rightcoronary artery angioplasty to the obtuse marginal in[**Month (only) 359**] of '[**14**] stent to the right coronary artery in[**2114-11-28**] angioplasty to the posterolateral branch ofthe right coronary artery in [**2116-6-28**] who presented withunstable angina x3 weeks to an outside hospital. Patientstates that he has been
chest pain
DISEASE
free for approximatelyseven years prior to approximately three weeks ago when his
chest pain
DISEASE
recurred.Patient reports that the
chest pain
DISEASE
was his typical anginabut mild compared to previous experiences and resolved with1-2 nitroglycerin. these symptoms sometimes occurred at restover the past three weeks. His episodes have increased infrequency over the past three weeks. Patient denies anyassociated symptoms such as
shortness of breath nausea
DISEASE
or
vomiting
DISEASE
.On the evening of admission the patient awoke from sleepwith 9/10
chest pain
DISEASE
and
diaphoresis
DISEASE
and took six sublingualnitroglycerin as well as aspirin without resolution of chest
pain
DISEASE
so he called ambulance. Patient was brought to anoutside hospital where ECG changes showed inferior STelevations and anterior ST depressions. Patient receivedHeparin drip Morphine and nitroglycerin at the outsidehospital and became
chest pain
DISEASE
free. Patient also receivedRetavase at the outside hospital.Patient had been scheduled for elective cardiaccatheterization at [**Hospital1 **] therefore he wastransferred to [**Hospital1 **] [**First Name (Titles) **] [**2123-3-26**] thesame evening that he presented to the outside hospital. Inthe ambulance upon transfer patient had recurrent
chest pain
DISEASE
and received a second dose of Retavase. The patient'sinferior ST changes had resolved by the time he arrived atthe Emergency Room at [**Hospital1 **] and he wasoriginally
pain
DISEASE
free. However his
pain
DISEASE
recurred and arepeat electrocardiogram showed ST elevations approximately 1mm in the inferior leads st
depression
DISEASE
in V1 and V2 and 1 & avlwith t wave inversion in avl.The patient was therefore broughtfrom the Emergency Room to the Coronary Cath Laboratory.At catheterization the patient was found to have 80% mid
left circ stenosis
DISEASE
as well as 90% lesion in the RCA betweentwo previous stents. The patient received two hepacoat stents tohisright coronary artery with good flow afterwards. Patient wasthen transferred to the Coronary Care Unit for furthermanagement. Upon arrival at the Coronary Care Unit thepatient denied any symptoms such as
chest pain
DISEASE
or shortnessof breath.Review of systems was notable for skin lesions that thepatient states has been diagnosed as shingles.PAST MEDICAL HISTORY:1.
Coronary artery disease
DISEASE
.2.
Hypertension
DISEASE
.3.
Hypercholesterolemia
DISEASE
.4.
Cirrhosis
DISEASE
secondary to alcohol use which per the patienthas resolved.5. Status post cholecystectomy.SOCIAL HISTORY: Patient smokes [**9-7**] cigarettes per day.Also drinks alcohol socially but denies drug use.FAMILY HISTORY: [**Name (NI) **] mother passed away from a
myocardial infarction
DISEASE
in her 70s and patient's father passedaway from a
myocardial infarction
DISEASE
in his 50s.REVIEW OF SYSTEMS: Was otherwise noncontributory.PHYSICAL EXAM ON ADMISSION: Middle-aged gentleman lying inbed in no apparent distress with normal S1 S2 regular rateand rhythm with no murmurs or extra heart sounds. Patient'svital signs: Heart rate in the 70s respiratory rate 18blood pressure 104/69 height 6'0Admission Date: [**2112-5-7**] Discharge Date: [**2112-7-7**]Service: GENERAL SURGERYHISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old manwith a history of
coronary artery disease
DISEASE
status postcoronary artery bypass graft times three in [**2104-2-26**]
hypertension
DISEASE
aortic insufficiency and
hiatal hernia
DISEASE
who presented with
postprandial epigastric pain
DISEASE
followed by
nausea
DISEASE
and
vomiting
DISEASE
. The patient denied any shortness of
breath diaphoresis palpitations
DISEASE
. He states that this
pain
DISEASE
is different from the
pain
DISEASE
that he had when he had his
myocardial infarction
DISEASE
. When seen in the Emergency Room thepatient was given aspirin morphine heparin and he wasadmitted to rule out
myocardial infarction
DISEASE
. The patient'samylase and lipase were found to be elevated consistent with
pancreatitis
DISEASE
.PAST MEDICAL HISTORY:1. Coronary artery bypass graft in [**2104**].2.
Hypertension
DISEASE
.3. Aortic insufficiency.4. Hiatal
hernia
DISEASE
.5. Echocardiogram with an ejection fraction of 44 to 48%.MEDICATIONS:1. Lopressor.2. Aspirin.ALLERGIES: No known
drug allergies
DISEASE
.HOSPITAL COURSE: The patient was admitted to the MedicalService in which care I did not partake in during that time.The patient was seen by General Surgery for a consultation of
abdominal pain
DISEASE
. The rest of his labs included ALT 15 AST21 alkaline phosphatase 99 total bilirubin 0.7 amylase111 lipase 164 albumin 3.The patient underwent an extensive work-up which eventuallyrevealed that he had an obstructing lesion at the fourth partof the duodenum and proximal jejunum at the area of theligament of Treitz and therefore was taken for anexploratory laparotomy on [**2112-5-20**]. The patient had aexploratory laparotomy and lysis of
adhesions
DISEASE
takedown ofsplenic flexures biopsy of peritoneal metastasesduodenal-jejunal bypass placement of feeding jejunostomytube. Please see Operative Note for further detail.Postoperatively the patient was admitted to the SurgicalIntensive Care Unit for a week for close cardiac monitoring.The patient afterwards continued to have
nausea
DISEASE
and
vomiting
DISEASE
. The patient had a prolonged
ileus
DISEASE
and
gastroparesis
DISEASE
which became evident postop and likely stemmed fromlongstanding
duodenal obstruction
DISEASE
as well as his age andphysical status which required TPN use. The patienttolerated tube feeds well. Once TPN was discontinued the[**Hospital 228**] hospital stay was thus characterized as slowlyprogressing nutrition p.o. and then there would be episodesof
nausea
DISEASE
and
vomiting
DISEASE
then the patient would start over withtube feeds p.o. and his feedings were slowly advanced.UGI study showed that the contrast passed through the nativeduodenum as well as the bypasss loop and upper endoscopyshowed that the duodenojejunostomy was widely patent. Thushe was treated with reglan and erythromycin for
gastroparesis
DISEASE
with slow improvement clinically.His cultures while in the hospital: He had transient episodeof
urinary sepsis
DISEASE
and urine cultures at that time showedPseudomonas treated with IV antibiotics and thenCiprofloxacinAdmission Date: [**2190-7-14**] Discharge Date: [**2190-7-19**]Date of Birth: [**2130-9-22**] Sex: MService:HISTORY OF PRESENT ILLNESS: The patient is a 59 year oldmale with a history of
Parkinson's disease
DISEASE
status post deepbrain electrode placement who was transferred to [**Hospital1 346**] for
atrial fibrillation
DISEASE
and
flutter
DISEASE
with slow ventricular response and symptomatic
bradycardia
DISEASE
.On the day prior to admission the patient noted an episodeof
dyspnea weakness
DISEASE
and
diaphoresis
DISEASE
which was more severethan he had ever experienced before and was found by hisnurse to have a heart rate in the 40s and systolic bloodpressure in the 90s. Electrocardiogram demonstrated atrialflutter with 5:1 block. He was started on Dopamine tomaintain his blood pressure and then entered a junctionalrhythm. He was then noted over the next 12 hours to go inand out of sinus as well as
atrial fibrillation
DISEASE
. The patienthas had recurrent symptoms of
light-headedness
DISEASE
and
diaphoresis
DISEASE
but is not certain if they correlate withchanges in his heart rhythms. The patient's only newmedications have been Kefzol and Terazosin. He denies any
fever
DISEASE
or
chills
DISEASE
but has had
chest tingling
DISEASE
and
numbness
DISEASE
. Ofnote the patient had the power generators placed for hisdeep brain electrode stimulation on [**2190-7-1**] and they wererecently turned on. He was admitted to [**Hospital1 190**] from [**2190-7-7**] to [**2190-7-11**] for a question ofsuperficial skin
infection
DISEASE
status post pacer power generatorplacement and was discharged on a fourteen day course ofKefzol.PAST MEDICAL HISTORY:1.
Parkinson's disease
DISEASE
.2. Depression.3. Status post subthalamic deep brain electrode placement.4. Pyloric stenosis status post pyloroplasty.ALLERGIES:1. Paxil.2. Cogentin.MEDICATIONS ON ADMISSION:1. Amantadine 100 mg p.o. three times a day.2. Sinemet 25/250 mg one half tablet q3hours while awake.3. Carbamazepine 200 mg p.o. twice a day.4. Tolterodine 1 mg p.o. twice a day.5. Klonopin 0.5 mg p.o. q.a.m.6. Quinine 325 mg p.o. twice a day.7. Mirapex 0.5 mg p.o. at 0500 0900 1300.8. Mirapex 0.25 mg p.o. at 1800.9. Trazodone 150 mg p.o. q.h.s. p.r.n.10. Kefzol two grams intravenously q8hours until [**2190-7-21**].11. Terazosin 10 mg p.o. once daily.SOCIAL HISTORY: The patient denies any tobacco history. Hehas distant alcohol use. He lives at home alone.FAMILY HISTORY: The patient denies any history of coronary
artery disease
DISEASE
or
arrhythmias
DISEASE
in his family.PHYSICAL EXAMINATION: On physical examination the patientwas afebrile temperature 99.6 heart rate 75 blood pressure150/80 respiratory rate 20 oxygen saturation 96% on twoliters via nasal cannula. In general the patient is anobese male in no apparent distress. Head and neckexamination revealed anicteric sclera. The pupils are equalround and reactive to light and accommodation. Extraocularmovements are intact. Neck supple and no
carotid bruits
DISEASE
.The lungs were clear to auscultation bilaterally. The chestwall had two well healed surgical incisions approximately 4.0centimeters in length with no drainage or
erythema
DISEASE
on hisbilateral anterior chest. Cardiac examination revealed anirregularly irregular rhythm with no murmurs. The abdomenwas benign. The extremities had no
edema
DISEASE
with 2[** **] Date: [**2197-6-25**] Discharge Date: [**2197-6-28**]Date of Birth: [**2130-9-22**] Sex: MService: MEDICINE
Allergies
DISEASE
:AnticholinergicsOther / Eldepryl / Amitriptyline / Cogentin /PaxilAttending:[**First Name3 (LF) 800**]Chief Complaint:FallsMajor Surgical or Invasive Procedure:RIJ placementHistory of Present Illness:66 yo man from NH with h/o
parkinson's disease
DISEASE
s/p deep brainstimulation presented from [**Hospital3 **] s/p fall x 3 in last2 days. Struck head with one fall (transitioning from wheelchairto chair) hit his head on carpet. Some
dysuria
DISEASE
no
fevers
DISEASE
someSOB. No HA no LOC no
seizures
DISEASE
no weakness/pain..In the ED initial vs were: T 99.5 HR74 BP149/79 RR18 O2Sat97.Then spiked to 100.5. Was given APAP. UA positive withleukocytosis. Patient was given cipro levophed for five minutesbut developed CP while he was on it so it was discontinued.While in ED had afib with RVR with rate in 140s. Now 120s.
Hypotensive
DISEASE
to SBP80s with that HR. RIJ CVL was placed. CXRpending. EKG without changes per ED physician. [**Name10 (NameIs) **] to unitfor hypotension/tachycardia..VS: HRs 107-110s BP101/83 RR 30 O2Sat:94% on 2L NC.On the floor patient had some low back
pain
DISEASE
initially whengetting situated in bed but this resolved quickly. Otherwise hehad no complaints specifically no complaints of SOB
chest pain
DISEASE
dizziness palpitations
DISEASE
.Past Medical History:#
Parkinsons disease
DISEASE
X 17 years s/p deep brain stimulation [**2190**]followed by Dr. [**First Name (STitle) **]# Chronic
LBP
DISEASE
# SSS (aflutter with severe
bradycardia
DISEASE
) s/p [**Company 1543**] Sigmadual-chamber pacemaker followed by Dr. [**Last Name (STitle) **]# Superficial
thrombophlebitis
DISEASE
[**5-13**] treated briefly with lovenox#
HTN
DISEASE
#
Obesity
DISEASE
Social History:Retired. Multiple jobs before. He currently resides at [**Location (un) 6927**] Rest Home ([**Hospital3 **]). They administer his medsto him. He denies tobacco or alcohol use. Walks with a walker[**3-7**] parkinsons disease.Family History:Great Aunt with
Parkinson's Disease
DISEASE
. Daughter and son arehealthy.Physical Exam:General: Alert oriented no acute distress masked
facies
DISEASE
HEENT: Sclera anicteric MMM oropharynx clearNeck: supple JVP not elevated no LADLungs: Clear to auscultation bilaterally no
wheezes rales
DISEASE
ronchiCV: Irregularly irRegular rhythm tachycardic normal S1 Admission Date: [**2162-12-21**] Discharge Date: [**2163-1-3**]Service: CARDIOTHORACIC
Allergies
DISEASE
:Penicillins / PercocetAttending:[**First Name3 (LF) 1283**]Chief Complaint:80 year old white female with DOE for the past year.Major Surgical or Invasive Procedure:Aortic valve replacement(21mm CE Perimount) [**2162-12-21**]History of Present Illness:This 80 year old white female has had DOE for 1 year. An echoin [**3-11**] showed [**Location (un) 109**] of 0.8 cm2. She underwent cardiac cath on[**2162-11-15**] which revealed: AV peak gradient of 64mmHg [**Location (un) 109**] of0.46 cm2 30% LMCA 40% D1 lesion 50%
RCA stenosis
DISEASE
and
pulmonary HTN
DISEASE
. She is now admitted for elective AVR.Past Medical History:
HTN
DISEASE
Admission Date: [**2163-8-11**] Discharge Date: [**2163-8-15**]Service: ORTHOPAEDICS
Allergies
DISEASE
:Penicillins / Percocet / Heparin AgentsAttending:[**First Name3 (LF) 64**]Chief Complaint:CC: Left hip
pain
DISEASE
Major Surgical or Invasive Procedure:[**2163-8-11**] Hip surgeryHistory of Present Illness:HPI: 81 yo woman w/ PMH sig for s/p bovine AVR periop A.Fib(oncoum and amio)
HTN
DISEASE
CAD PTCA X2 PVD
hypercholesterolemia
DISEASE
waswalking with a cane got stuck in a rug and fell forward and ontoher left hip. Denied any
dizziness lightheadedness
DISEASE
CP/palpitations and LOC after fall. Admitted to OSH reveled aL hip
fracture
DISEASE
. Preop negative nuclear stress. She was at theOSH x 2d and admitted to ortho for Hip fracture..Given preoperative FFP and she underwent an uncomplicated orthoprocedure screw placed. Post op course notable for some hiveson thigh and left ear given 25 benadryl X 1. Pt also noted tobe brady to
50s
DISEASE
not symptomatic no intervention andtransferred to medicine this morning..Now pt states that the
pain
DISEASE
is controlled with medications. Shehas not moved her bowels since monday. not passing gas but ptwithholding voluntarily. Admission Date: [**2168-8-26**] Discharge Date: [**2168-9-2**]Service: MEDICINE
Allergies
DISEASE
:Penicillins / Percocet / Heparin AgentsAttending:[**First Name3 (LF) 106**]Chief Complaint:SOBMajor Surgical or Invasive Procedure:thoracentesisHistory of Present Illness:Ms. [**Known lastname 6940**] is an 86 year old female with
diastolic CHF
DISEASE
afibCAD [**Known lastname 1192**] MS/MR s/p bioprosthetic AVR ([**2162**]) and h/o CVAwho presents with
shortness of breath
DISEASE
on transfer from[**Location (un) 5871**]/OSH..Patient was doing okay at home 24hr home O2 3-4L until thismorning when her daughter thought she was more short of breathand tachypneic. Per daughter patient had a high Admission Date: [**2109-5-16**] Discharge Date: [**2109-5-19**]Date of Birth: [**2048-9-16**] Sex: MService: MEDICINE
Allergies
DISEASE
:CodeineAttending:[**First Name3 (LF) 2145**]Chief Complaint:R arm
pain swelling erythema
DISEASE
Major Surgical or Invasive Procedure:NONEHistory of Present Illness:Mr. [**Known lastname 6943**] is a 60 y/o male with
polycythemia
DISEASE
[**Doctor First Name **] for past 20Admission Date: [**2172-3-26**] Discharge Date: [**2172-4-23**]Date of Birth: [**2109-12-16**] Sex: FService: MEDICINE
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 30**]Chief Complaint:
Febrile
DISEASE
unresponsive--Admission Date: [**2166-6-10**] Discharge Date: [**2166-7-4**]Date of Birth: [**2135-2-7**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Last Name (NamePattern1) 495**]Chief Complaint:
sepsis
DISEASE
Major Surgical or Invasive Procedure:PEG placementIntubation tracheostomyCentral lineHistory of Present Illness:This is a 31 yo F with a past medical history significant for
hemorrhagic CVA
DISEASE
3 years ago with a prolonged post
CVA
DISEASE
coursec/b tracheostomy and residual
aphasia
DISEASE
and r-sided
hemiparesis
DISEASE
aspiration
pneumonias
DISEASE
who per her mother has had a recentprogressive decline with difficulty swallowing. On the day ofadmission to the OSH the patient developed
abdominal pain
DISEASE
and
vomiting
DISEASE
and was admitted for further work-up. She was found tobe tachycardic to the 140's
febrile
DISEASE
to 103.8 (rectal) BP138/114. A femoral line was placed as PIV access and a RIJ wereunable to be obtained. She had progressive
respiratory distress
DISEASE
and was then intubated for airway protection. She wastransferred to the OSH ICU for presumed aspiration
pneumonia
DISEASE
sepsis ARF
DISEASE
and
respiratory failure
DISEASE
..At the OSH the patient was startedlevofloxacin/timentin/vancomycin OG tube was placed was givenIVF and was placed on steroids. Per her mother she has no
seizure
DISEASE
history but is maintained on valproate and wasrestarted on this at the OSH. She was transferred to [**Hospital1 18**] tothe [**Hospital Unit Name 153**] for further management of her
renal failure
DISEASE
andpossible
sepsis
DISEASE
..When the patient arrived she was on a propofol gtt and washaving tongue and
eyelid fasciculations
DISEASE
. She withdrew to
pain
DISEASE
but was otherwise unresponsive. Vitals were stable.Past Medical History:-
Diabetes Mellitus
DISEASE
type 1 (dx at age 3) hx of hypoglycemicepisodes- CVA (
hemorrhagic
DISEASE
) at 27 with
residual aphasia
DISEASE
andr-hemiparesis tracheostomy post CVA now decannulated.- blindness in one eye- history of aspiration
pneumonia
DISEASE
- although patient is on valproate no reported history of
stroke
DISEASE
-
depression
DISEASE
Social History:remote smoking history at age 18 lived in CA and has lived atthe Greenery since coming to MA.Family History:healthy brother/sister. Maternal family history of DM.Physical Exam:Vitals: T 99.4 HR 90 BP 138/88 sats 98% on AC 450x16 peep 5FiO2 60%General: intubated sedated not responding to voice.HEENT: left
ptosis
DISEASE
. PERRL. anicteric.Neck:supple JVP elevated 8cmH20Lungs: diffuse rhonchiChest: RRR II/VI sem at baseAbd: soft NT mild distention Admission Date: [**2166-7-13**] Discharge Date: [**2166-8-14**]Date of Birth: [**2135-2-7**] Sex: FService: EMERGENCY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2565**]Chief Complaint:
seizure hypoglycemia
DISEASE
Major Surgical or Invasive Procedure:trans-esophageal echocardiogrambronchoscopyHistory of Present Illness:31yoF w/ h/o
DM1 HTN
DISEASE
s/p left sided
hemorrhagic CVA
DISEASE
(3 yrsago) s/p trach/PEG/chronically indwelling catheter presents toED from [**Hospital **] rehab today after having had witnessed Admission Date: [**2167-1-16**] Discharge Date: [**2167-1-24**]Date of Birth: [**2135-2-7**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 603**]Chief Complaint:Fevers and EmesisMajor Surgical or Invasive Procedure:IR-guided Midline IV [**2167-1-23**]History of Present Illness:31yoF with
DM1 HTN
DISEASE
and
R hemiplegia
DISEASE
and
aphasia
DISEASE
s/p
CVA
DISEASE
whopresented from NH with
fevers
DISEASE
to 101F and
emesis
DISEASE
. She was
febrile
DISEASE
and hyperglycemic in
DKA
DISEASE
for which she was admitted tothe MICU..MICU course: She was admitted for
DKA hypernatremia
DISEASE
and
UTI
DISEASE
Admission Date: [**2171-7-5**] Discharge Date: [**2171-7-12**]Date of Birth: [**2135-2-7**] Sex: FService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 4095**]Chief Complaint:altered mental statusMajor Surgical or Invasive Procedure:Endotracheal intubation at OSH prior to arrival extubated at[**Hospital1 18**]Temporary Dobhoff tube placement for tubefeedsHistory of Present Illness:36 y.o female with pmhx of
CVA
DISEASE
[**2158**] DM type 1 found to beunresponsive with a serum glucose of 28. She developed
seizure
DISEASE
like activity and
hypoxemia
DISEASE
at [**First Name4 (NamePattern1) 189**] [**Last Name (NamePattern1) **] where she wasintubated with return of secretions from ETT. The
seizure
DISEASE
likeactivity improved with ativan. Neurology consulted for continuedtwitches EEG ordered loaded with Dilantin in ED. Recievedtotal 6mg Ativan with control of sz-like activity. Given empiricabx: Vanc/Unasyn initially now Vanc/Zosyn. Has had Klebs
UTIs
DISEASE
Resistant only to ampicillin in their system.Cultures arecurrently pending and has left sided infiltrate on imaging..Of note the patient was hypothermic initially now normothermicwithWBC 11.5 BMP wnl BUN 21 Cr 1.4 ABG 7.35/35/170 Trop neg.(
DM1
DISEASE
)No LP was done. She just came in this morning at 7amAdmission Date: [**2139-3-24**] Discharge Date: [**2139-3-27**]Date of Birth: [**2070-5-3**] Sex: FService: NEUROSURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 78**]Chief Complaint:
Headaches cerebral aneurysm
DISEASE
Major Surgical or Invasive Procedure:Endovascular angiogramHistory of Present Illness:68 year old female who is known to the neurosurgical service forknown R ICA
aneurysm
DISEASE
3mm reported in 10/[**2137**]. She was seen in[**10-12**] in our office for
incidentaly
DISEASE
found R ICA
aneurysm
DISEASE
and hasnot been seen since.Pt reports HA with sudden onset about 6 - 7 days ago withoutimprovement. Pt with
emesis
DISEASE
x last 3 days - intolerant of food/liquids and meds. Describes
emesis
DISEASE
as projectile. Pt went toPCP last friday and had o/p CT. That CT reported Admission Date: [**2160-3-20**] Discharge Date: [**2160-4-4**]Service: MEDCHIEF COMPLAINT: Shortness of breath.HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old gentlemanwith a history of
congestive heart failure
DISEASE
with the lastechocardiogram prior to examination revealing an ejectionfraction of 75 percent with 3Admission Date: [**2147-4-18**] Discharge Date: [**2147-4-25**]Date of Birth: [**2071-4-24**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 1505**]Chief Complaint:chest pressure with exertionMajor Surgical or Invasive Procedure:[**2147-4-21**]Coronary artery bypass grafting x3 withleft internal mammary artery graft to left anteriordescending reverse saphenous vein graft to the marginalbranch and diagonal branch.History of Present Illness:75 year old male with history of
diabetes
DISEASE
and
hyperlipidemia
DISEASE
referred by PCP for exercise stress test for symptoms of chestdiscomfort with exertion. He reports that he is quite active butrecently has noticed that his walking is limited by left sidedchest pressure that resolves with rest. ETT demonstrated 2-4 mmhorizontal ST segment depressions inferiorly and in leads V4-V6.In addition ST segment elevation was noted in lead aVR. He wasalso symptomatically
hypotensive
DISEASE
with
lightheadedness
DISEASE
. He nowunderwent cardiac catheterization that revealed significant
coronary artery disease
DISEASE
.Past Medical History:
coronary artery disease
DISEASE
s/p CABG
hypertension
DISEASE
hyperlipidemia
DISEASE
type 2 DM
pericarditis
DISEASE
[**2089**]recent shingles
peripheral neuropathy
DISEASE
s/p R 4th trigger finger releases/p banding
internal hemorrhoids
DISEASE
Social History:Lives with wife.Worked at Sears and the Museum of Fine Arts - now retired.Denies hx of smoking.Drinks 2-3 glasses of wine each week.
Denies
DISEASE
illict drug use.Family History:Mother:
stroke
DISEASE
CABG (80s)Sister:
Diabetes
DISEASE
Physical Exam:VS: 125/67 60 18 97%RAGENERAL: Thin elderly male NAD. Oriented x3. Mood affectappropriate.HEENT: NCAT. Sclera anicteric. PERRL EOMI. Mild
erythema
DISEASE
ofposterior oropharynxNECK: Supple no JVD no
carotid bruits
DISEASE
CARDIAC: PMI located in 5th intercostal space midclavicularline. RR normal S1 S2. No m/r/g. No thrills lifts. No S3 orS4.LUNGS: No
chest wall deformities scoliosis
DISEASE
or
kyphosis
DISEASE
. Respwere unlabored no accessory muscle use. CTAB no crackles
wheezes or rhonchi
DISEASE
.ABDOMEN: Soft NTND. No HSM or
tenderness
DISEASE
.EXTREMITIES: No c/c/e. Left radial site for cath
clean/dry/intact
DISEASE
good radial pulses no
hematoma
DISEASE
SKIN: No
stasis dermatitis ulcers
DISEASE
scars or
xanthomas
DISEASE
.PULSES:Right: DP 2Admission Date: [**2152-1-20**] Discharge Date: [**2152-1-21**]Date of Birth: [**2087-10-19**] Sex: MService:HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 5573**] is a 64-year-oldgentleman who underwent heart catheterization on [**2151-12-28**]. On the basis of that test because of multiple vesseldisease it was planned that he go ahead and have coronaryartery bypass graft surgery. The patient had been seen in[**2149-11-12**] at which time an 80-85% right internal
carotid stenosis
DISEASE
with no significant stenosis on the leftside was identified by duplex examination. His carotiddisease was asymptomatic and had been asymptomatic in theintervening two years. At the present time Mr. [**Known lastname
5573
DISEASE
**] had
chest pain
DISEASE
associated with exercise only and afterconsultation with the various members of his cardiology teamit was decided to proceed with a carotid endarterectomy onthe right side as a preliminary to his coronary artery bypassgraft procedure.The patient also has a history of radical prostatectomy andhad previously had a penile implant under the care of Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].Stress testing on [**2151-12-13**] demonstrated moderatelysevere reversible defect in the inferior wall and mildreversible defect in the anterior wall with an ejectionfraction of 46%.ADMISSION MEDICATIONS:1. Zestril 5 mg daily.2. Procardia 30 mg daily.3. Atenolol 50 mg daily.4. Aspirin 162 mg daily.5. Lipitor 20 mg daily.6. Imdur 30 mg daily.PHYSICAL EXAMINATION ON ADMISSION: The patient was a healthyappearing gentleman with no
neurological deficits
DISEASE
. Thepatient had a right carotid bruit. His chest was clear. Hehad otherwise normal pulses in the upper extremities and wasotherwise in reasonable cardiac shape for the procedure.HOSPITAL COURSE: On the day of admission the patientunderwent a right carotid endarterectomy with patchangioplasty using a thin-walled knitted Dacron. That wasdone under general anesthesia. His postoperative course wascompletely uneventful. He was discharged to home on thefollowing day after his surgery taking his usualmedications. He will return for coronary artery bypass graftin three days.DISCHARGE DIAGNOSIS: Coronary
artery disease
DISEASE
which was threevessel in type right carotid stenosis.OPERATION ON THE DATE OF ADMISSION: Right carotidthromboembolectomy and patch angioplasty.MEDICATIONS ON DISCHARGE: As above. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**] M.D. [**MD Number(1) 1478**]Dictated By:[**Last Name (NamePattern4) 5574**]MEDQUIST36D: [**2152-1-21**] 08:13T: [**2152-1-22**] 06:24JOB#: [**Job Number 5575**]Admission Date: [**2152-1-24**] Discharge Date: [**2152-1-28**]Date of Birth: [**2087-10-19**] Sex: MService: CARDIOTHORACICHISTORY OF PRESENT ILLNESS: This is a 67 year-old man with apast medical history significant for
noninsulin
DISEASE
dependent
diabetes mellitus
DISEASE
as well as
prostate cancer
DISEASE
status postradical prostatectomy who had previously had a penile implantunder the care of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name4 (NamePattern1) **][**Last Name (NamePattern1) 5576**]. The patient initially had cardiaccatheterization in [**2142**] following a stress test prior to hissurgery for
prostate cancer
DISEASE
. At that time he underwentpercutaneous transluminal coronary angioplasty of his rightcoronary artery which was complicated by a
VF arrest
DISEASE
whichwas managed by defibrillation and CPR on [**2142-11-15**].He then began having
exertional anginal symptoms
DISEASE
last yearhowever no angina at rest. He also began complaining of
acid reflux symptoms
DISEASE
beginning in [**2151-9-12**] which wastreated by Prilosec. He underwent a stress test [**2151-12-13**] and subsequently another cardiac catheterization in[**2151-12-12**] which revealed 80% left anterior descending
coronary artery disease
DISEASE
70%
left circumflex disease
DISEASE
and 80%right
coronary artery disease
DISEASE
with an EF of 45%.MEDICATIONS PREOPERATIVELY: Procardia Lipitor AtenololImdur Glucophage Zestril and aspirin.HOSPITAL COURSE: The patient underwent coronary arterybypass graft times four on [**2152-1-24**] with the leftinternal mammary to the left anterior descending saphenousvein graft to the obtuse marginal saphenous vein graft tothe diagonal and saphenous vein graft to the posteriordescending coronary artery. Total cardiopulmonary bypasstime was 94 minutes total cross clamp time was 50 minutes.The patient was transferred in stable condition to theCoronary Care Unit being A paced at 80 beats per minute instable condition on neo-synephrine at .5 mcg per kilogram perminute and Propofol at 30 mcg per kilogram per minute. Thepatient was extubated very early postoperative day onewithout complications. Postoperative day one the patientawake alert and oriented times three moving all of hisextremities and following commands in sinus rhythm at 79.Vital signs are stable with adequate urine output. Thepatient's blood sugars were high so an insulin drip wasstarted per protocol. Still on the neo drip at .25.Afebrile with a white blood cell count of 9.8 and hematocritof 32.6 BUN 16 creatinine .9. The plan for the day was towean the patient's neo-synephrine to off. Postoperative daytwo no events over the past 24 hours aside from theneo-synephrine being weaned off. The patient still in sinusrhythm at 73 vital signs are stable. Afebrile with a whitecount of 9.3 and a hematocrit of 28.4. A BUN of 15creatinine of .8. The plan was to begin the patient'sLopressor and Lasix.On physical examination the patient with scattered rhonchi atthe lower bases which clears with coughing. The patientstill is being covered for heparin subQ for fluctuating bloodsugars. The patient was transferred to the floor laterpostoperative day two in stable condition with complaints ofmild
pain
DISEASE
at incision sites which was relieved withPercocet. Urology came by to see the patient because therewas a difficult Foley placement the day of surgery. Urologythen removed the Foley catheter the day of consult which was[**1-26**] postoperative day two. The patient had nocomplaints with voiding and a condom catheter was in place.Urology explained to the patient that he may leak more thenusual after the dilatation and he was instructed to follow upwith Dr. [**Last Name (STitle) **] after discharge from the hospital.Postoperative day three the patient awake alert and orientedwith complaints of mild
incisional pain
DISEASE
relieved withPercocet. The patient's Foley was discontinued and thepatient now complains of
incontinence
DISEASE
since his Foleyremoval. Postoperative day four the patient was doing wellwith no difficulty urinating. The patient was dischargedhome on [**2152-1-28**] with discharge instructionsincluding follow up with Dr. [**Last Name (STitle) 70**] in four to six weeksas well as follow up with his cardiologist in two to fourweeks.DISCHARGE MEDICATIONS: Aspirin 325 mg po q day Atorvastatin10 mg po q day Metoprolol 12.5 mg po b.i.d. Lasix 20 mg poq 12 hours Metformin 500 mg po b.i.d. Percocet one to twotabs po q 4 to 6 hours prn
pain
DISEASE
Colace 100 mg po b.i.d. prn
constipation
DISEASE
.DISCHARGE DIAGNOSIS:
Coronary artery disease
DISEASE
status post coronary artery bypassgrafting. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] M.D. [**MD Number(1) 75**]Dictated By:[**Doctor Last Name 5577**]MEDQUIST36D: [**2152-3-30**] 12:42T: [**2152-3-31**] 09:31JOB#: [**Job Number 5578**]Admission Date: [**2183-8-6**] Discharge Date:Service: ICUCHIEF COMPLAINT: Hypercarbic hypoxemic
respiratory failure
DISEASE
HISTORY OF PRESENT ILLNESS: 79-year-old white female with ahistory of
chronic obstructive pulmonary disease
DISEASE
hypertension
DISEASE
paroxysmal
atrial fibrillation
DISEASE
presents fromrehabilitation facility following an episode of
tachypnea
DISEASE
hypoxia
DISEASE
and
obtundation
DISEASE
requiring endotracheal intubation.The patient is status post a recent prolonged hospitalizationfrom [**7-4**] to [**7-25**] for
gallstone pancreatitis
DISEASE
requiringopen cholecystectomy and choledochoduodenostomy on [**7-3**] byDr. [**Last Name (STitle) 1305**] with a long hospitalization complicated by E. coli
sepsis
DISEASE
a lower
gastrointestinal bleed
DISEASE
with negativecolonoscopy
volume overload
DISEASE
and a
postoperative abdominal abscess
DISEASE
culture positive for
vancomycin-resistant
DISEASE
enterococcus requiring CT-guided drainage. The patient alsosuffered
C. difficile colitis
DISEASE
during this admission. Towardthe end of her hospitalization the patient was noted to haveacute
tachypnea
DISEASE
pH 7.27 CO2 70 which resolved with minimalintervention the following day. The patient was dischargedto a skilled nursing facility on [**7-25**] on a plan forlinezolid for four weeks for her
VRE abscess
DISEASE
and Flagyl fortwo weeks for her C.
difficile colitis
DISEASE
.At the skilled nursing facility the patient has done poorlywith continued
lethargy anorexia
DISEASE
and
depression
DISEASE
. She wasnoted to have decreased sodium to 119 on [**8-3**] which wasquestion of serum-inappropriate antidiuretic hormone. Thepatient developed
cough
DISEASE
on [**7-29**] for which she was startedon
Robitussin
DISEASE
and yesterday she was noted to have
hypoxia
DISEASE
with an oxygen saturation of 93% on 2 liters nasal cannula.This morning shortly after breakfast the patient was notedto become more
tachypneic
DISEASE
and somnolent having an oxygensaturation in the 60s on 2 liters improving to 97% on 100%non-rebreather. She became increasingly somnolent andbecame completely unresponsive. The patient was bag maskventilated and referred to [**Hospital1 188**] for further evaluation.In the Emergency Department she was afebrile with heartrate in the 80s blood pressure 140/80 oxygen saturation 90%on 100% non-rebreather. She was unresponsive to voice and
pain
DISEASE
. The patient was subsequently intubated withimprovement in her mental status following intubation. A CTAof the chest was performed without evidence of pulmonary
embolism
DISEASE
with scattered
ground-glass opacities
DISEASE
slightlyincreased right greater than left. Electrocardiogram waswithout significant change. A head CT was negative for acute
bleed
DISEASE
or
cerebrovascular accident
DISEASE
. After receiving 4 litersof normal saline ceftriaxone Flagyl and lasix the patientwas transferred to the Intensive Care Unit.Upon arrival to the Intensive Care Unit the patient spiked atemperature to 101 and dropped her systolic blood pressurefrom 130s to the 80s. The patient received a 1 liter fluidbolus without significant change. She was subsequentlystarted on dopamine.PAST MEDICAL HISTORY:1.
Hypertension
DISEASE
2. Chronic
obstructive pulmonary disease
DISEASE
FEV-1 1.74 in [**2176**]3.
Atrial fibrillation
DISEASE
4. Congestive
heart failure
DISEASE
with an ejection fraction of60%
basal septal hypertrophy
DISEASE
1 to 2Admission Date: [**2198-11-23**] Discharge Date: [**2198-11-27**]Date of Birth: [**2135-1-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 45**]Chief Complaint:
PEA arrest
DISEASE
.Major Surgical or Invasive Procedure:temporary pacemaker placementpermanent Pacemaker placement [**2198-11-26**]History of Present Illness:Pt was in USOH awaiting R THR collapsed while celebrating afuneral mass was down for 1 min prior to EMS arrival found tobe
pulseless
DISEASE
atrial activity noted on stips but only occasionalwide qrs complexes could not transcut pace got atropine andcalcium gluc went to [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **] was intubated for protection K6.6 HCO3 13 and Cr 2.7. Got kayexylate bicarb gtt lasix andextubated. ECG w/RBBB LAD LAFB and sig PR delay so sent herefor pacer. R IJ pacer wire screwed in but still temporary.Transferred to [**Hospital1 18**] for permanent pacer and further managment.Past Medical History:PMH:
HTN dyslipidemia
DISEASE
CRI (not formally dx per pt) OA w/ hip
pain
DISEASE
awaiting R THR h/o chronic low potassium and severe
HTN
DISEASE
per pt-baseline trifasicular blockSocial History:Pt is a priestFamily History:non-contributoryPhysical Exam:t 98.9BP 131/79HR 64Tele: v-paced/ few PVC's with compensatory pausesO2 sat 92%RAGen: elder male lying in bed NADHEENT: JVP flat MMM PERRLA EOMIHeart: s1 s2 RRR. no MRGLungs: bibasilar crackles otherwise CTABExt: 1Admission Date: [**2183-8-6**] Discharge Date: [**2183-9-15**]Service:PRIMARY DIAGNOSIS:1. Volume
overload anasarca
DISEASE
.2. Status post posterior
trach perforation
DISEASE
and repair.3.
Respiratory failure
DISEASE
with
ventilatory dependence
DISEASE
. Mechanical
ventilatory dependence
DISEASE
.4.
Atrial fibrillation
DISEASE
.5. Clostridium
difficile infection
DISEASE
.6. Malnourishment.7. Sepsis. Status post treatment and resolution.8. Pneumonia ventilatory associated status post resolution and treatment.9. Anemia.10.
Pleural effusions
DISEASE
.11.
Goiter
DISEASE
.12.
Hypothyroidism
DISEASE
13.
Urinary tract infection
DISEASE
numerous including pseudomonas.14. Questionable
myopathy
DISEASE
.15.
Yeast infection
DISEASE
of the urinary tract.16.
Thrombocytopenia
DISEASE
subsequent resolution.17. Right internal jugular non-occlusive clot.18.
Hyponatremia
DISEASE
subsequently resolved.19. Tracheostomy.20.
Hypothyroidism
DISEASE
.21.
Gastroesophageal reflux disease
DISEASE
.SECONDARY DIAGNOSIS:1. Status post cholecystectomy and choledochoduodenostomy.2. Vancomycin resistant
enterococcus bacteremia
DISEASE
in abscess.3. History of lower
gastrointestinal bleed
DISEASE
.HISTORY OF PRESENT ILLNESS: Mrs. [**Known firstname **] [**Known lastname 5579**] is a79-year-old female with
chronic obstructive pulmonary
DISEASE
disease
hypertension
DISEASE
paroxysmal
atrial fibrillation
DISEASE
whopresents from Shore House Rehabilitation following episodesof
tachypnea hypoxemia
DISEASE
and
obtundation
DISEASE
requiringendotracheal intubation. The patient is status post recenthospitalization from [**7-4**] to [**2183-7-25**] for
gallstone
DISEASE
pancreatitis
DISEASE
requiring open cholecystectomy andcholedochoduodenostomy on [**2183-7-11**] by Dr. [**Last Name (STitle) 1305**] withhospitalization complicated by E. coli
sepsis
DISEASE
volume
overload
DISEASE
and bilateral
pleural effusion atrial fibrillation
DISEASE
and postop
abdominal abscess
DISEASE
which grew out VancomycinResistant Enterococcus.The patient subsequently had a gallbladder drainage by CTguidance on [**2183-7-18**]. The patient suffered C. diff
colitis
DISEASE
atprior hospitalization. Towards the end of hospitalizationwas noted to have acute
tachypnea
DISEASE
. She was subsequentlydischarged to Shore House on [**2183-7-25**] on antibioticsLinezolide for four week course for her Vancomycin resistant
enterococcus abscess
DISEASE
and Flagyl for 14 day course for C. diff
colitis
DISEASE
.At the Shore House however the patient was doing poorly withcontinued
lethargy anorexia
DISEASE
and
depression
DISEASE
. The patient wasnoted to develop
hyponatremia
DISEASE
. She apparently developed
cough
DISEASE
on [**7-29**] for which she was treated with
Robitussin
DISEASE
andthe day prior to admission was noted to have
hypoxemia
DISEASE
withO2 saturations 90% on two liters nasal cannula.On the morning of presentation to [**Hospital1 190**] the patient shortly was noted to become more
tachypneic
DISEASE
and somnolent with oxygen saturation in the 60'sand requiring 100% non-rebreather. The patient subsequentlythen became unresponsive and was subsequently started manualartificial respirations and was sent to [**Hospital1 190**] for further evaluation.In the Emergency Room she was afebrile heart rate in the 80sand blood pressure 140/80 oxygen saturation 90% on 100%non-rebreather unresponsive. The patient subsequentlyintubated at the Emergency Room at [**Hospital1 190**]. She was admitted to the Intensive Care Unitfor further treatment.PAST MEDICAL HISTORY:1.
Hypertension
DISEASE
.2.
Gastroesophageal reflux disease
DISEASE
FEV 1 of 1.74 70% predicted.3.
Atrial fibrillation
DISEASE
.4. Congestive
heart failure
DISEASE
with ejection fraction of 60% Basal septal hypokinesis.5. History of
Gastrointestinal bleed
DISEASE
secondary to aspirin.6. Degenerative joint disease.7.
Migraine headaches
DISEASE
.8. Cataracts.9. Substernal
goiter
DISEASE
with
hypothyroidism
DISEASE
status post biopsy.ALLERGIES: Aspirin which causes
gastrointestinal bleed
DISEASE
.MEDICATIONS ON PRESENTATION:1. Linezolide 200 mg p.o. b.i.d.2. Flagyl 500 mg p.o. q 8 hours.3. Percocet4. Atenolol 100 mg q day.5. Ranitidine 150 mg p.o. q day.6. Levoxyl 75 mcg q day.7. Lasix 40 mg p.o. q day.8. Amiodarone 200 mg p.o. q day.9. Florinef 0.1 mg p.o. q day.10. Prednisone 30 mg p.o. q day.PHYSICAL EXAMINATION: Upon presentation the patient wassubsequently intubated temperature 101 heart rate 70 to 80and
atrial fibrillation
DISEASE
. Blood pressure 107/48 on Dopamine.Skin was dry. Head eyes ears nose and throat:Normocephalic atraumatic. Pupils are equal round andreactive to light and accommodation. Oropharynx
dry
DISEASE
. Neck:Prominent external jugular veins. Lungs: Bilaterally coarsebreath sounds. Cardiac: Irregular rate and rhythm nomurmurs rubs or gallops. Abdomen: Surgical site healingwell.
Hyperactive bowel sounds soft
DISEASE
nontender topalpation. Extremities: No
edema
DISEASE
peripheral pulses 2Admission Date: [**2183-9-25**] Discharge Date: [**2183-10-29**]Date of Birth: 04/[**Numeric Identifier 5590**] Sex: FService: [**Hospital **] MEDICAL INTENSIVE CARE UNITHISTORY OF PRESENT ILLNESS: The patient is a 79-year-oldfemale with multiple medical problems and a prolonged recentIntensive Care Unit stay. She was readmitted with preppedand draped. In [**Month (only) **] of this year she had
gallstone
DISEASE
pancreatitis
DISEASE
requiring open cholecystectomy and her course
congestive heart failure atrial fibrillation
DISEASE
C-diff
respiratory failure
DISEASE
followed by
failure
DISEASE
to wean and becauseof this she had a tracheostomy the placement of which wascomplicated by tracheal tear requiring placement of aspecialized trachea and urgent repair. Additionally she hasan unclear
myopathic neuropathic
DISEASE
process resulting ingeneralized total body weakness. She was sent to [**Location (un) 511**]admission after
respiratory distress
DISEASE
and reported
granulation
DISEASE
tissue in her tracheal site. Plans were made for abronchoscopy in the morning. She denied
shortness of breath
DISEASE
chest pain
DISEASE
or
cough
DISEASE
.PAST MEDICAL HISTORY: 1. Hypertension. 2. Atrial
fibrillation
DISEASE
. 3. Vent dependent believed to be secondary to
myopathy neuropathy
DISEASE
. 4. Recent C-diff. 5. Volume
overload
DISEASE
. 6. Malnutrition. 7. Status post tracheal
perforation
DISEASE
. 8.
Goiter hypothyroid
DISEASE
. 9. Right IJ clot.10.
Gastroesophageal reflux disease
DISEASE
. 11. Status postcholecystectomy. 12. Status post
intra-abdominal abscess
DISEASE
.ALLERGIES: ASPIRIN LEVOFLOXACIN VANCOMYCIN GENTAMICIN.MEDICATIONS ON ADMISSION: Synthroid 75 q.d. Metoprolol 25b.i.d. Prilosec 40 q.d. Flagyl 500 t.i.d. Paxil 20 q.d.Vitamin C 500 b.i.d. Zinc 220 q.d. Trazodone 25 q.h.s.Zofran p.r.n. Coumadin Lasix 20 q.d. Promote tube feeds 65cc/hr.PHYSICAL EXAMINATION: Vital signs: Pulse 100 bloodpressure 109/65 oxygen saturation 99% on room air. General:She was an elderly white female in no acute distress. HEENT:Unremarkable. Lungs: Coarse breath sounds throughout.Cardiovascular: Irregularly irregular with normal S1 andS2. Abdomen: Benign. Extremities: There was 3Admission Date: [**2103-10-7**] Discharge Date: [**2103-10-11**]Date of Birth: [**2054-1-14**] Sex: FService:HISTORY OF PRESENT ILLNESS: The patient is a 49-year-oldwoman with a negative past medical history who at 4:45 p.m.on the day of admission complained of left-sided
numbness
DISEASE
and tingling. At 5:15 p.m. she noted right upper quadrant
numbness
DISEASE
. The patient picked up the phone and was unable tohold on to the phone. She dropped the phone and then beganhaving difficulty walking. She was taken to [**Hospital3 3583**]and she was unable to walk once she got to [**Hospital3 3583**].She had a head CT of the brain which showed a 3.5-cmright-sided mass with hyperintense ring enhancement and mild
edema
DISEASE
.PAST MEDICAL HISTORY: Benign.PAST SURGICAL HISTORY: Cesarean section 14 years ago andvaricose vein stripping.ALLERGIES: SULFA to which she gets a
rash
DISEASE
.MEDICATIONS ON ADMISSION: No medications.PHYSICAL EXAMINATION ON PRESENTATION: The patient had ablood pressure of 131/69 temperature 98.4 heart rate 91respiratory rate 11 to 18 saturation 97% to 98% on room air. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**] M.D. [**MD Number(1) 343**]Dictated By:[**Last Name (NamePattern1) 344**]MEDQUIST36D: [**2103-10-11**] 15:20T: [**2103-10-11**] 14:26JOB#: [**Job Number
5605
DISEASE
**] (cclist)Admission Date: [**2191-5-9**] Discharge Date: [**2191-5-13**]Date of Birth: [**2120-12-22**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 5606**]Chief Complaint:Chief Complaint: LLE
pain
DISEASE
and SOBReason for MICU transfer: close hemodynamic monitoringMajor Surgical or Invasive Procedure:noneHistory of Present Illness:The patient is a 70 yo M with a hx of
PE/DVT
DISEASE
[**8-23**] whoseanticoagulation was recently stopped [**3-30**] after a neg CTA andnegative doppler study who now presents with recurrent
DVT/PE
DISEASE
.He reports experiencing left sided lower extremity
edema
DISEASE
thathas been present since his initial
DVT
DISEASE
presentation [**8-23**]. Thisbecame significantly work for the past 2 days along with leftfoot
pain
DISEASE
. He presented to [**Hospital3 **] where he wasfound to have an extensive
DVT
DISEASE
in the LLE and was given a doseof lovenox 100 mg at 0220 and coumadin 10 mg at 0200. He alsoreportedly endorsed some discomfort and a CTA revealed a saddlePE. He was subsequently transferred to [**Hospital1 18**] for furthermanagement. Pt reports he is only minimally ambulatory due toAdmission Date: [**2105-11-10**] Discharge Date: [**2105-11-15**]Date of Birth: [**2049-2-26**] Sex: MService: MEDICINE
Allergies
DISEASE
:Quinine / VicodinAttending:[**First Name3 (LF) 2297**]Chief Complaint:Sepsis/confusionMajor Surgical or Invasive Procedure:R groin and L IJ central lines R wrist and L groin arteriallinesHistory of Present Illness:56 yo m transferred from [**Hospital **] hospital w/ end stage liver dz[**3-6**]
hepatitis sclerosing cholangitis UC
DISEASE
on the transplantlist and normally followed at [**Hospital1 336**] (no beds available) whopresented from OSH
septic
DISEASE
on peripheral pressors. He had been inrehab x 3 months more recently had
failure
DISEASE
to thrive. Todaypresents to [**Hospital1 **] ER with a BP 82/39 HR 45 WBC 18creatinine 4.4 Bili 24. Given daptomycin and imipenem at OSH..In the ED vitals were t 90 hr 50 bp 82/40 sat 98% ra. Notedto have a lactate of 12.2 and an ABG 7.04/19/122. Patient givendaptomycin and imipenem for broad coverage. R IJ attempted butfailed. L femoral line placed. Was intubated for airwayprotection requiring minimal sedation given underlying
encephalopathy
DISEASE
. Was started on levophed for BP support. Onplacement of OGT noted to have Admission Date: [**2132-3-11**] Discharge Date: [**2132-4-2**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 5608**]Chief Complaint:abnormal CXR
anemia
DISEASE
Major Surgical or Invasive Procedure:intubationcentral line placementbronchoscopyarterial line placementHistory of Present Illness:The patient is an 84M with
prostate CA
DISEASE
CAD
HTN
DISEASE
who presentswith 2 weeks
dry cough
DISEASE
. He saw his hematologist who ordered aCXR for the
cough
DISEASE
and it showed extensive heterogenousopacification in the right lung. Because of these abnormalfindings his PCP told him to come to the ED for evaluation.He has had the intermittent
dry cough
DISEASE
for about two weeks buthas not had
fevers chills
DISEASE
weight loss
DISEASE
change in appetite
shortness of breath nausea vomiting diarrhea
DISEASE
. He has noticedsome
fatigue
DISEASE
as he used to walk two miles a day until the
cough
DISEASE
started but notes he is limited by
fatigue
DISEASE
not DOE. No othersymptoms. In the ED he was noted to have a dropping Hct (25.4down from 29.6 the previous day). He has not noted blood in hisstool or had any lightheadedness. He was guaiac negative. He wasbeing worked up for
anemia
DISEASE
and was not found to have evidence ofiron folate or
B12 deficiency
DISEASE
in [**2-4**]. SPEP was also normal.After discussion with his PCP by the [**Name9 (PRE) **] he is being admittedfor expedited workup of CXR findings and
anemia
DISEASE
. Pulmonology wasconsulted in the ED.ROS:-Constitutional: []WNL []
Weight loss
DISEASE
[x]Fatigue/Malaise []Fever[]
Chills/Rigors
DISEASE
[]Nightsweats []Anorexia-Eyes: [x]WNL []Blurry Vision []
Diplopia
DISEASE
[]Loss of Vision[]Photophobia-ENT: []WNL [x]Dry Mouth []Oral
ulcers
DISEASE
[]Bleeding gums/nose[]Tinnitus []
Sinus pain
DISEASE
[]Sore throat-Cardiac: [x]WNL []
Chest pain
DISEASE
[]Palpitations []LE
edema
DISEASE
[]Orthopnea/PND []DOE-Respiratory: []WNL []SOB []Pleuritic
pain
DISEASE
[]
Hemoptysis
DISEASE
[x]Cough-Gastrointestinal: [x]WNL []
Nausea
DISEASE
[]Vomiting []Abdominal pain[]Abdominal Swelling []
Diarrhea
DISEASE
[]
Constipation
DISEASE
[]Hematemesis[]Hematochezia []Melena-Heme/Lymph: [x]WNL []Bleeding []
Bruising
DISEASE
[]
Lymphadenopathy
DISEASE
-GU: [x]WNL []Incontinence/Retention []Dysuria []
Hematuria
DISEASE
[]Discharge []Menorrhagia-Skin: [x]WNL []
Rash
DISEASE
[]
Pruritus
DISEASE
-Endocrine: [x]WNL []Change in skin/hair []Loss of energy[]Heat/Cold intolerance
-Musculoskeletal: [x]WNL []Myalgias []Arthralgias []Back
pain
DISEASE
-Neurological: []
Numbness of extremities []Weakness
DISEASE
ofextremities []Parasthesias []Dizziness/Lightheaded []Vertigo
[]Confusion []Headache-Psychiatric: [x]WNL []Depression []Suicidal Ideation-Allergy/Immunological: [x] WNL []Seasonal AllergiesPast Medical History:
prostate cancer
DISEASE
diagnosed [**2130**] getting treated with hormonaltherapy followed by Dr. [**Last Name (STitle) 365**]CAD s/p CABG [**2112**]
dyslipidemia
DISEASE
HTN
DISEASE
NSVT
DISEASE
SSS s/p ICD/PMsevere
left ventricular dysfunction
DISEASE
(EF 20% in [**2-3**])Social History:He lives in [**Hospital3 **] with his wife. [**Name (NI) **] has a son who has hadmultiple bypass surgeries and significant
cardiac disease
DISEASE
. Hehad a daughter who passed away from
cancer
DISEASE
. He has no smokinghistory. Reports drinking alcohol drinking one glass ofalcohol every night prior to dinner. He is retired.Family History:Son w/ multiple CABGsdaughter w/
cancer
DISEASE
Physical Exam:Physical Exam:Appearance: NADVitals: T: 96.4 BP: 124/59 HR: 71 RR: 20 O2: 100% 2LEyes: EOMI PERRL conjunctiva clear noninjected anicteric no
exudate
DISEASE
ENT: MoistNeck: No JVD no LAD no thyromegaly no
carotid bruits
DISEASE
Cardiovascular: RRR nl S1/S2 no m/r/gRespiratory: exam limited by coughing poor air movementdiffusely
wheezy
DISEASE
Gastrointestinal: soft non-tender non-distended no
hepatosplenomegaly
DISEASE
normal bowel soundsMusculoskeletal/Extremities: no clubbing no
cyanosis
DISEASE
no joint
swelling
DISEASE
no
edema
DISEASE
in the bilateral extremitiesNeurological: Alert and oriented x3 fluent speech no pronatordrift no
asterixis
DISEASE
sensation WNL CNII-XII intact strength[**4-1**] in upper and lower extremities bilaterallyIntegument: warm no
rash
DISEASE
no
ulcer
DISEASE
Psychiatric
DISEASE
: appropriate pleasantHematological/Lymphatic: No
cervical lymphadenopathy
DISEASE
Pertinent Results:[**2132-3-11**] 11:15AM GLUCOSE-116* UREA N-23* CREAT-1.1 SODIUM-133
POTASSIUM-4.4 CHLORIDE-98
DISEASE
TOTAL CO2-26 ANION GAP-13[**2132-3-11**] 11:15AM CK(CPK)-117[**2132-3-11**] 11:15AM CK-MB-4[**2132-3-11**] 11:30AM cTropnT-0.01[**2132-3-11**] 11:15AM WBC-7.9 RBC-2.85* HGB-8.5* HCT-25.4* MCV-89MCH-29.9 MCHC-33.6 RDW-13.9[**2132-3-11**] 11:15AM PLT COUNT-274[**2132-3-10**] 10:10AM LD(LDH)-259* TOT BILI-0.5 DIR BILI-0.2 INDIRBIL-0.3[**2132-3-10**] 10:10AM HAPTOGLOB-492*[**2132-3-10**] 10:10AM IgG-1510 IgA-278 IgM-58[**2132-3-10**] 10:10AM RET AUT-1.3[**2132-3-10**] 09:45AM WBC-7.9 RBC-3.34* HGB-10.0* HCT-29.6* MCV-89MCH-29.9 MCHC-33.7 RDW-14.2[**2132-3-10**] 09:45AM NEUTS-74.5* LYMPHS-11.7* MONOS-4.7 EOS-9.0*BASOS-0.2[**2132-3-10**] 09:45AM PLT COUNT-266#[**2132-3-11**] 03:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021[**2132-3-11**] 03:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG[**2132-3-11**] 03:30PM URINE RBC-0-2 WBC-2 BACTERIA-FEW YEAST-NONEEPI-0-2[**3-10**] PA AND LATERAL CHEST RADIOGRAPH:Multiple midline sternotomy wires are unchanged in position.Small surgical clips are seen along the left cardiac bordercompatible with prior CABG. The two-chamber pacemaker with ICDis seen with leads in the right ventricle and right atriumunchanged. There is mild
cardiomegaly
DISEASE
. The mediastinal and hilarcontours are unchanged. Pulmonary vasculature is unremarkable.There is no
pneumothorax
DISEASE
or large
pleural effusion
DISEASE
.New extensive heterogeneous opacification is seenpredominately in the right lung with peripheral consolidationand lesser degree of central opacification. Right- sided volumeloss suggests a chronic process. Left
basilar opacities
DISEASE
arecompatible with
atelectasis
DISEASE
and the left lung is otherwiseclear.IMPRESSION:Compared to [**2124**] study new extensive heterogeneousopacification in the right lung with peripheral consolidationand lesser degree of central opacification.
Loss of right lung
DISEASE
volume suggests a subacute process. Differential is broadincluding
pneumonia postinfectious
DISEASE
and cryptogenic organizing
pneumonia
DISEASE
multifocal
bronchioloalveolar cell carcinoma
DISEASE
chroniceosinophilic
pneumonia
DISEASE
Churg- [**Doctor Last Name 3532**] vasculitis amiodarone
toxicity
DISEASE
.[**3-11**] CXR:No interval change over one day in appearance of diffuseairspace
opacity
DISEASE
involving the right hemithorax. Additional
opacity
DISEASE
seen in the left base also unchanged. Originaldifferential diagnosis stands and multifocal
pneumonia
DISEASE
cannot beexcluded.CT CHEST: FINDINGSThe patient is intubated. Pooling of secretions are above thecuff of theendotracheal tube. Small layering bilateral non-hemorrhagic
pleural effusions
DISEASE
are increased on the right and new on the left. Diffuseextensive areas of
ground-glass opacity
DISEASE
peribronchial consolidation and
bronchiectasis
DISEASE
haveworsened in the left lung minimally improved in the right upperlobe. Rightcentral catheter tip is in the mid SVC. Transvenous pacemakerlead terminatesin a standard position. NG tube tip is out of view below thediaphragm. Dense
calcifications
DISEASE
are in the native coronary arteries. There ismild-to-moderate
cardiomegaly
DISEASE
. The cardiac [**Doctor Last Name 1754**] are hypodense. This suggests
anemia
DISEASE
.
Calcification
DISEASE
in the aortic valve is of unknown hemodynamicsignificance. APwindow and prevascular lymph nodes have increased in sizeAdmission Date: [**2170-3-6**] Discharge Date: [**2170-3-14**]Date of Birth: [**2140-8-29**] Sex: FService: MedicineHISTORY OF PRESENT ILLNESS: The patient is a 29-year-oldfemale with
end-stage renal disease
DISEASE
on hemodialysis who wasadmitted to the Medical Intensive Care Unit from theEmergency Department with
sepsis
DISEASE
. The patient was in herusual state of health until after her usual Mondayhemodialysis session. The session lasted three hours and wascomplicated by line
thrombosis
DISEASE
.Upon arriving home she felt profoundly fatigued was
vertiginous
DISEASE
and had diffuse long
bone pain
DISEASE
felt
febrile
DISEASE
and was nauseated and vomited once. She also noted mild
shortness of breath
DISEASE
with mild
pleuritic chest pain
DISEASE
. Thepatient took Tylenol with no relief.On the morning of [**3-6**] she presented to theEmergency Department and was found to have a blood pressureof 90/60 which was responsive to 1 liter of normal saline.The patient had generalized
weakness
DISEASE
and mild
abdominal pain
DISEASE
.A left external jugular central line was attempted butbecame infiltrated and was removed with resulting
hematoma
DISEASE
.A successful right femoral line was then placed. Hertemperature was 101 with a white blood cell count of 35.8.She was transiently hypoxic briefly requiring a face mask tosustain an oxygen saturation of greater than 90%. She wasalso found to have a potassium of 9.2. She was given insulinD50 calcium gluconate and bicarbonate. An EKG showedpeaked T waves with widening of the QRS intervals. Patientwas taken for hemodialysis during which time blood cultureswere drawn and Vancomycin was given empirically.REVIEW OF SYSTEMS: Diarrhea. Patient traveled to [**State 108**]
nausea weakness
DISEASE
mild
headache
DISEASE
mild
photophobia
DISEASE
. Patienthas gained 30 pounds and lost 30 pounds over the past year.Patient denied
shortness of breath chest pain dysuria
DISEASE
neckstiffness
abdominal pain
DISEASE
sick contacts vision changes andleg
pain
DISEASE
.PAST MEDICAL HISTORY:1.
End-stage renal disease
DISEASE
secondary to
IgA nephropathy
DISEASE
diagnosed 12 years ago. Patient has been on hemodialysissince [**2164**] status post multiple A-V graft revisions.2. Right Permacath for the past four months status post trialof peritoneal dialysis. Patient is on the renal transplantlist.3.
Hypertension
DISEASE
.4. Major
depressive disorder
DISEASE
on Zoloft and Seroquel.5.
Pseudotumor cerebri
DISEASE
in [**2164**].6. Positive PPD status post INH in [**2156**].7.
Left ovarian cyst
DISEASE
removal.8.
Hyperkalemia
DISEASE
status post
A-V graft thrombus
DISEASE
in [**2169-3-4**].MEDICATIONS:1. Renagel t.i.d.2. Nephrocaps q.d.3. Sertraline 150 mg p.o. q.h.s.4. Atenolol 25 mg p.o. b.i.d.5. Zestril 5 mg p.o. b.i.d.6. Epogen with hemodialysis.7. Seroquel 100 mg p.o. q.d.ALLERGIES: Patient has a questionable
allergy
DISEASE
to Vancomycinwhich causes
pruritus
DISEASE
.SOCIAL HISTORY: The patient lives with her mother andsister. She works as a cytotechnologist. She deniessmoking. She has limited alcohol use and she denies anydrug use.FAMILY HISTORY: No significant family history.PHYSICAL
EXAM
DISEASE
ON ADMISSION: Temperature was 101.0 bloodpressure 156/104 heart rate 101 respiratory rate 22 andoxygen saturation 98% on 2 liters. In general the patientwas alert and oriented times three in no acute distress.HEENT: Facial
rash
DISEASE
consistent with
acne
DISEASE
. Pupils are equalround and reactive to light. Extraocular muscles areintact. Visual fields were full bilaterally. Conjunctivaewere injected diffusely on the right. Oropharynx showed nolesions. Neck was supple without bruits masses orthyromegaly. There was no
lymphadenopathy
DISEASE
. Cardiovascular:Nondisplaced PMI S1 greater than S2 no murmurs rubs orgallops. Pulmonary: Clear to auscultation bilaterally nowheezes or egophony. Abdomen: Normoactive bowel soundssoft nontender nondistended no
hepatosplenomegaly
DISEASE
nomasses and no bruits. Groin: Right femoral line clean
dry
DISEASE
and intact. Extremities: No
clubbing cyanosis
DISEASE
or
edema
DISEASE
. 2Admission Date: [**2183-9-25**] Discharge Date: [**2183-10-29**]Service:DISCHARGE DIAGNOSES:1. Ventilatory dependence.2.
Atrial fibrillation
DISEASE
.3. Neuropathy and
weakness
DISEASE
.4. Hyperthyroidism.5.
Gastroesophageal reflux disease
DISEASE
.6. Status post gallbladder removal.KNOWN ALLERGIES AT THE TIME OF DISCHARGE: 1. Levofloxacincauses a
rash
DISEASE
. 2. Vancomycin causes
hearing loss
DISEASE
. 3.Aspirin Celebrex and non-steroidal anti-inflammatory drugsthe patient cannot tolerate. 4. Gentamycin cannot tolerateper the patient's son.MEDICATIONS ON DISCHARGE: 1. Vitamin C 500 q.d. 2. Paxil40 mg q.h.s. 3. Bactrim double strength one tab b.i.d.until [**2183-10-21**]. 4. Prednisone 60 mg q.d. until[**2183-11-4**] per neurology request. 5. Coumadin 3 mg poq.h.s. adjust to goal INR of 2.0 to 3.0. 6. Regular insulinper sliding scale. 7. Captopril 37.5 mg t.i.d. 8. Colace100 b.i.d. 9. Prevacid 30 mg q.d. 10. Senna two tabsb.i.d. 11. Digoxin 0.125 mg q.d. 12. Synthroid 75micrograms q.d. 13. Trazodone 25 mg q.h.s. prn for sleep.NUTRITIONAL NEEDS: The patient is lactose intolerant.VENTILATORY SETTINGS: Mrs. [**Known lastname 5579**] has been attempted touse a Admission Date: [**2183-9-25**] Discharge Date: [**2183-10-29**]Service:HISTORY OF PRESENT ILLNESS: The following discharge summarywill cover the time period from [**10-15**] through [**2183-10-28**].Please see previous discharge summary for information onpatient's admission diagnosis and medications.HOSPITAL COURSE:1. Gastrointestinal. On [**10-16**] the patient developed
nausea
vomiting
DISEASE
and
abdominal pain
DISEASE
. Because of this she was notdischarged to rehabilitation at [**Location (un) 511**] Center Hospitalas had been previously planned. Due to her symptoms a CTscan was obtained which revealed the patient had an
ileus
DISEASE
.There were no abscesses or other processes that could beidentified. The neurology service was consulted regardingpossibility of this
ileus
DISEASE
being related to the patient's
myopathy
DISEASE
but felt this was unlikely since skeletal musclemyopathies typically do not also involve smooth muscle of theGastrointestinal tract. A Gastrointestinal consult wasobtained who had no additional thoughts on what could becausing the patient's
ileus
DISEASE
and recommended bowel rest. Thepatient was kept off tube feeds for two days after which timethey were restarted at a low rate of 20 cc's an hour ascompared to her goal rate of 65 cc's per hour. The patientappeared to tolerate this reasonably well and the tube feedswere increased. When they reached the rate of 30 cc's anhour however the patient developed
nausea
DISEASE
and
vomiting
DISEASE
asecond time. Tube feeds were again stopped and her bowel wasrested for several days.On [**10-24**] it was decided that because the patient was unableto tolerate tube feeds at a reasonable rate she would bestarted on TPN for nutrition. At the time of this dictationon [**10-27**] the patient was reporting decreased
abdominal pain
DISEASE
and no further
nausea
DISEASE
or vomiting. She additionally had beensuccessful in moving her bowels and treated with ColaceSenokot and Fleet enemas. The suspicion of the team at thispoint in time is that her
ileus
DISEASE
is resolving however veryslowly. Her tube feeds will need to be started at a veryslow rate advanced extremely gently as tolerated withcaution being taken because when the rate is increased toabruptly she does tend to develop
nausea
DISEASE
and
vomiting
DISEASE
. Shewill be discharged out on no tube feeds they can be startedwhen she arrives at [**Location (un) 511**] Center for rehabilitation.She will be discharged out on TPN which she can continue.Additionally we will maintain her on [**Doctor Last Name **] and Colace.2. Pulmonary. The patient continued to do well on a trachmask and in fact tolerated trach mask ventilation for fivedays in a row with no support from mechanical ventilator.Because of this she was deemed safe to go to the floorsomething which the team and the patient's family were veryhappy with as it was thought this could be a trialpreliminary to transferring her to rehabilitation home. On[**10-21**] she was transferred to the floor. Unfortunately howeveron [**10-22**] she was found to be hypoxic to the low 80's on thefloor. She was suctioned with thick tenacious darksecretions came out her O2 sats increased to the mid-80's.Chest x-ray was consistent with a left sided
opacity
DISEASE
throughout which was new. She was transferred back to theIntensive Care Unit with ventilatory support and bronchoscopywas performed which revealed purulent drainage from the leftmainstem sample was sent. Chest x-ray after bronchoscopyrevealed markedly improved air space. O2 saturationsincreased to 98% on only .4 FIO2. Following this episode thepatient was rested in IMV for several days. At the time ofthis admission she was feeling better and feeling strongenough to try pressor support ventilation again.The teams thinking is that perhaps the patient needs to berested each night in an MV mode letting her use only a trachmask for five days may have been to much to soon and in thefuture we will get her to tolerate pressor support and resther on the night and possibly during the day allowing her tobreath through the trach mask. Currently she is beingweaned this will need to be continued at [**Hospital1 **].Per discussion with the family the pulmonary attending isplanning to call the pulmonary attending at [**Hospital1 **]to communicate the patient's need regarding ventilatorymanagement.3. Infectious disease. On [**10-16**] the patient's urine grew outEnterobacter which was sensitive only to Mirpenum and oneother [**Doctor Last Name 360**]. She was treated with Mirpenum for seven days.At approximate completion of the 7 days course the patient'sBAL sample from her bronch grew out pseudomonas which wasresistant to Mirpenum. Because of this switched to Zosynwhich the pseudomonas was sensitive to. She will bedischarged on this and need to complete a 10 to 14 daycourse. Additionally she was started on Flagyl for possibleC. diff given that she was complaining of
abdominal pain
DISEASE
andwas feeling extremely weak. Of note she did not have
diarrhea
DISEASE
. She did seem to get better after starting theFlagyl so she will need to complete a 14 day course of thisas well for empiric therapy for C. diff.Also of note the patient had one set of blood culturespositive for coag negative staph however it was deemed thatthis was a contaminant and the decision was made not to treatafter consultation with
Infectious Disease
DISEASE
service.4. Neurological. The patient continued to show improvementin her strength while on 60 mg of Prednisone a day. Theoriginal plan had been for her to be treated for 4 weeks with60 mg of Prednisone empirically and then follow-up with theneuromuscular service for a decision as to whether or not tocontinue this. However after approximately 2-1/2 weeks oftherapy the patient had issues with
infectious disease
DISEASE
asdetailed above including
urinary tract infection
DISEASE
and
pulmonary infection
DISEASE
. Because of these issues with highlyresistant bacteria it was deemed that the best thing to dowould be to taper the steroids.On approximately [**10-22**] the patient was cut from 60 to 40 mg ofPrednisone a day and on [**10-27**] the day of this dictation thepatient was cut to 20 mg a day. She will need to continuethis slow taper until the steroids had been weaned to off.If her improvement in neurologic function continues even offthe steroids then she can probably never start on steroidsagain however if she shows a decline once she is offsteroids this will further enforce the theory that thesteroids are what has been treating her
myopathy
DISEASE
and once sheis clear for
infectious
DISEASE
issues she should be restarted onsteroids in the future. She will follow-up with theneuromuscular service as detailed in her previous dischargesummary.5. Psychiatric. On one occasion the patient during thenight the patient became quite despondent and request thatshe did not wish to continue with this therapy as she wasincredibly frustrated. However the team had multiplediscussions on their rounds and at the time of this dictationthe patient's mood had significantly improved and her will tofight on actually seemed quite remarkable. She is continuedon her Paxil and at the present time the team did not see anyneed for additional
psychiatric
DISEASE
intervention.6. Communication. A family meeting was held on [**2183-10-27**]with the patient's two daughters son and husband as well asthe attending physician in the Intensive Care Unit Dr. [**First Name (STitle) **]Dr. [**First Name (STitle) **] the former Intensive Care Unit attending myselfDr. [**First Name (STitle) 916**] and the patient's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Discussion was heldas to the patient's status. We discussed the fact that thefamily had previously wished for the patient to haveresolution of all her issues prior to going torehabilitation. However we explained that her issues seemedto be taking quite sometime the resolve and that we will haveto accept the fact that her issues are stable and improvingalthough not completely resolved. Additionally was discussedthe fact that the patient was clearly ready forrehabilitation now and likely many of her problems includingher
pulmonary and gastrointestinal problems
DISEASE
may benefit fromgetting her out of bed and having her go to rehabilitation.The family was open to this and grateful for our assistance.Tentative plans were made to arrange for discharge to [**Hospital1 5593**] on [**2183-10-29**].An addendum to this discharge summary will be dictatedfollowing this detailing the events of the 15th and 16th.Please refer to that discharge summary for the exact meds atdischarge and discharge diagnosis.DIAGNOSIS AT TIME OF THIS DICTATION:1.
Respiratory failure
DISEASE
resulting in
ventilatory dependence
DISEASE
.2.
Myopathy
DISEASE
of unclear etiology.3.
Ileus
DISEASE
of unclear etiology.4. Pseudomonas
pneumonia
DISEASE
.5. Enterobacter
urinary tract infection
DISEASE
. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] M.D. [**MD Number(1) 292**]Dictated By:[**Last Name (NamePattern1) 1213**]MEDQUIST36D: [**2183-10-27**] 20:51T: [**2183-10-27**] 21:10JOB#: [**Job Number 5594**]Admission Date: [**2184-1-16**] Discharge Date: [**2184-1-20**]Service: [**Hospital1 212**]HISTORY OF PRESENT ILLNESS: This 79-year-old woman isadmitted for
respiratory distress hyponatremia
DISEASE
and
hyperkalemia
DISEASE
. This woman has had a complicated medicalcourse over the past six months which has included severalepisodes of
respiratory failure
DISEASE
difficulty to wean off aventilator tracheostomy placement complicated by trachealtear (requiring open sternotomy)
anasarca
DISEASE
atrial
fibrillation E.coli sepsis
DISEASE
pseudomonas urinary tract
infection VRE intraabdominal abscess
DISEASE
and
Clostridium
DISEASE
difficile colitis
DISEASE
. Her
ventilatory difficulties
DISEASE
were thoughtto be perhaps secondary to a myopathic process althoughmuscle biopsy results were inconclusive and not demonstrativeof inflammatory changes.Patient was admitted to [**Hospital1 **] [**10-28**]through [**2183-12-18**] and successfully weaned from theventilator there. She was transferred to [**Hospital1 5595**] [**2183-12-18**] where she was gradually reintroduced to p.o. feed andweaned from PEG feeds. She currently tolerates a pureeddiet. Her
atrial fibrillation
DISEASE
has been managed via ratecontrol as the Amiodarone she was previous on was felt topossibly contribute to her
myopathy
DISEASE
. She had been on Lasix(40 mg b.i.d.) on transfer from [**Hospital1 **] andnonetheless gained 12 pounds from [**12-28**] through[**1-15**]. Lasix was decreased to 20 mg q. day on [**1-12**] because her sodium was noted to be 129.On [**1-15**] the patient was noted to have increased
dyspnea
DISEASE
and
tachypnea
DISEASE
. She states she has had intermittent
dry cough
DISEASE
for several days. No subjective fevers or
chills
DISEASE
.She was transferred to [**Hospital1 69**]today with still more
dyspnea
DISEASE
/ tachypnea sodium of 126 anda potassium of 6.2.PAST MEDICAL HISTORY:1.
Hypertension
DISEASE
.2.
Atrial fibrillation
DISEASE
.3.
Diastolic dysfunction
DISEASE
(latest echo [**2183-9-30**] ejectionfraction of 70 to 80% (2Admission Date: [**2118-8-10**] Discharge Date: [**2118-8-12**]Date of Birth: [**2073-12-25**] Sex: FService: NEUROSURGERY
Allergies
DISEASE
:CodeineAttending:[**First Name3 (LF) 1854**]Chief Complaint:elective admission for
radionecrosis
DISEASE
resection due toradiosurgery of
AVM
DISEASE
Major Surgical or Invasive Procedure:Left craniotomy for
radionecrosis
DISEASE
resectionHistory of Present Illness:Presents for resection of
radionecrosis
DISEASE
s/p radiosurgery for
AVM
DISEASE
Past Medical History:seizuresh/o radio therapy for avm has resid
edema
DISEASE
causingseizuresAdmission Date: [**2190-5-16**] Discharge Date: [**2190-5-22**]Date of Birth: [**2139-4-22**] Sex: FService: CARDIOTHORACICHISTORY OF PRESENT ILLNESS: This 51 year-old female wasadmitted to an outside hospital with
chest pain
DISEASE
and ruled infor
myocardial infarction
DISEASE
. She was transferred here for acardiac catheterization.PAST MEDICAL HISTORY:
Hypertension fibromyalgia
DISEASE
hypothyroidism NASH
DISEASE
and
noninsulin
DISEASE
dependent
diabetes
DISEASE
.PAST SURGICAL HISTORY: Hysterectomy and cholecystectomy.SOCIAL HISTORY: She smokes a pack per day.MEDICATIONS ON ADMISSION: Hydrochlorothiazide AlprazolamUrsodiol and Levoxyl.She was hospitalized with Aggrastat nitroglycerin andheparin as she ruled in for
myocardial infarction
DISEASE
.ALLERGIES: No known
drug allergies
DISEASE
.Cardiac catheterization showed left anterior descendingcoronary artery diagonal 80% lesion circumflex 90% lesionand 90% lesion of the right coronary artery with a normalejection fraction. She was transferred from [**Hospital3 68**]to [**Hospital1 69**] for cardiaccatheterization. The results as above. Aftercatheterization she was referred to cardiothoracic surgeryand was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] and Dr. [**First Name4 (NamePattern1) 71**] [**Last Name (NamePattern1) 72**].Preoperative laboratories showed a sodium of 141 K 4.2chloride 105 CO2 24 BUN 12 creatinine 0.6 with a bloodsugar of 156. White count 8.9 hematocrit 44.2 plateletcount 201000. PT 13 PTT 26 with an INR of 1.2. CK was1511 on [**5-16**]. She was also followed by Dr. [**Last Name (STitle) 73**] ofcardiology and agreed to participate in both the Cariporideand Dermabond studies through cardiac surgery. The patientwas taken to the Operating Room on [**5-18**] and underwentcoronary artery bypass grafting times four with a leftinternal mammary coronary artery to the left anteriordescending coronary artery saphenous vein graft to rightposterior descending coronary artery saphenous vein graft todiagonal two and a saphenous vein graft to the obtusemarginal by Dr. [**Last Name (STitle) 70**].The patient was transferred to the Cardiothoracic IntensiveCare Unit in stable condition. On postoperative day numberone there were no events overnight. The patient wasextubated and was on a neo-synephrine drip at 0.3 microgramsper kilo per minute with the Cariporide infusing.Nitroglycerin had been turned off. Postoperative hematocritwas 30 with a K of 4.2 and a blood sugar of 139. CPK trendeddown to 357 and 379 with an MB of 15 to 16. The patient wasin sinus rhythm in the 80s with a stable blood pressure. Shewas alert and oriented. Her lungs were clear bilaterally.Heart was regular rate and rhythm. Her abdomen was benign.Her extremities were within normal limits. She wasneurologically stable. Her chest tubes were pulled onpostoperative day number three. She continued onperioperative antibiotics and was transferred out to thefloor.She was seen by physical therapy for evaluation. Onpostoperative day two she had no events overnight. She had atemperature max of 100.6. Her JP drain from her leg site wasremoved as was her Foley. Her Lopresor was increased to 50b.i.d. She began to ambulate and was out of bed. She haddecreased at the bases but was otherwise hemodynamicallystable. Her dressings were clean
dry
DISEASE
and intact. She wasseen by case management to determine the need for rehab. Herpacing wires were discontinued on postoperative day three.She continued to advance her ambulation. She had decreasedbreath sounds a the bases again on postoperative day threebut was stable and continuing to increase her physicaltherapy. Her incision was were clean
dry
DISEASE
and intact. Painwas managed with Percocet and Motrin. She was sating 92% onroom air on postoperative day number four the day ofdischarge with a temperature max of 99.3 blood pressure136/71 heart rate 93. She was alert oriented and had beenambulating well. Her lungs were clear bilaterally. Herexamination was otherwise benign.Her laboratories on the 9th showed a white count of 13.6hematocrit 28.7 platelet count 153000 BUN 15 creatinine0.5 sodium 141 glucose 100 K 3.8 magnesium 1.7 for whichshe received 2 grams of repletion. Calcium 1.08 for whichshe received 2 grams of repletion. She was discharged tohome on postoperative day four [**5-22**].DISCHARGE MEDICATIONS: Lasix 20 mg po q.d. times one weekK-Ciel 20 milliequivalents po q day times one week. Colace100 mg po q.d. Zantac 150 mg po b.i.d. enteric coatedaspirin 325 mg po q day Levoxyl 0.25 mg po q day Lopressor75 mg po b.i.d. Nicoderm 14 patch q.d. Xanax 2 mg q 4 to 6hours prn Ursodiol dosage not specified. The patient wasinstructed to return to preoperative dose. Percocet one totwo tabs po prn q 4 to 6 hours.The patient was afebrile. Incisions were healing well.DISCHARGE DIAGNOSES:1.
Hypertension
DISEASE
.2. Status post coronary artery bypass grafting times four.3. Fibromyalgia.4. Hypothyroidism.5. Noninsulin dependent
diabetes mellitus
DISEASE
.6. Question
NASH
DISEASE
.She was also instructed to follow up with her primary carephysician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 74**] in two weeks and follow up with Dr.[**Last Name (STitle) 70**] in the office in six weeks for postop follow up.Again the patient was discharged home on [**2190-5-22**]. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] M.D. [**MD Number(1) 75**]Dictated By:[**Last Name (NamePattern1) 76**]MEDQUIST36D: [**2190-7-7**] 08:16T: [**2190-7-7**] 11:56JOB#: [**Job Number 77**]Admission Date: [**2103-4-11**] Discharge Date: [**2103-4-18**]Service: MEDICINE
Allergies
DISEASE
:Enalapril / Ace InhibitorsAttending:[**First Name3 (LF) 1973**]Chief Complaint:Right arm tinglingMajor Surgical or Invasive Procedure:Left Craniotomy for resection of massHistory of Present Illness:Asked to eval this 86 year old white RHM who appears youngerthan his stated age for newly diagnosed brain mass. He takesdaily ASA and coumadin for AFIB. Pt and wife give history.They report that he has had frequent falls recently the latestbeing yesterday. He did strike his head yeadsterday but did nothave LOC or sz. He has baseline
incontinence
DISEASE
from prostate CAand straight caths 6 xs day for this. He feels that he has beenfalling due to
weakness
DISEASE
on his right side. Due to the falls hehas had exacerbation of his
back pain
DISEASE
. He stopped his coumadinone week ago for planned EDSI at [**Hospital1 **]. After hisEDSI he walked himself over to a neurology clinic requesting tobe seen - he had imaging and was sent here for neurosurgicalevaluation. Admits to
pain
DISEASE
at back of
head Denies dizziness
DISEASE
N/V
DISEASE
sz CP or SOB.Past Medical History:
HTN
DISEASE
MI [**06**]-20 yrs ago (no PPM / no stents)
Prostate CA s/p RT and hormone
DISEASE
therapy
sleep apnea
DISEASE
/ utilizes CPAP machinebaseline
incontinence
DISEASE
AFIBhigh cholesterolTB s/p 1 year of medical therapy many years ago.Social History:lives with wife at home (one fight of stairs to basement)retired manager remote tobacco use (quitAdmission Date: [**2103-10-7**] Discharge Date: [**2103-10-11**]Date of Birth: [**2054-1-14**] Sex: FService:HISTORY OF PRESENT ILLNESS: The patient is a 49 year oldwoman with a negative past medical history who on the day ofadmission noticed
numbness
DISEASE
and tingling of her left side thatprogressed to inability to walk. The patient was taken to[**Hospital3 3583**] where she had a head computerized tomographyscan and magnetic resonance imaging scan which showed a 3.5cm mass with some surrounding
edema
DISEASE
no mass effect nomidline shift right frontoparietal mass with hyperintenseregion.PAST SURGICAL HISTORY: Cesarean section 14 years ago andvaricose vein stripping.MEDICATIONS: She is on no medications.ALLERGIES: She has an
allergy
DISEASE
to sulfa which causes a
rash
DISEASE
.PHYSICAL EXAMINATION: On physical examination she is awakealert and oriented times three. Pupils fixed down to 4 mmbilaterally fluent language and oriented times three. Bloodpressure was 131/69 temperature 98.4 heartrate 91respiratory rate 11 to 18 saturations 97 to 98%. Lungs wereclear to auscultation. Cardiac was regular rate and rhythmno murmur rub or gallop positive bowel sounds nontendernondistended. 2Admission Date: [**2131-4-2**] Discharge Date: [**2131-4-6**]Date of Birth: [**2074-6-25**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1283**]Chief Complaint:
exertional angina
DISEASE
Major Surgical or Invasive Procedure:cabg x4/RCA endarterectomy [**2131-4-2**] (LIMA to LAD SVG to OM1 andOM2 SVG to PDA)History of Present Illness:56 yo male with several months of recurrent chest discomfort.Myoview showed large areas of lateral
ischemia
DISEASE
small area ofscar and anteroapical
ischemia
DISEASE
. Cath revealed LM 30% LAD 90%diag 1 100% diag 2 100% CX 70-90% OM1 70% OM 2 80% OM 3100% RCA 30-50% PDA 90% EF 50-55% trace MR LVEDP 21.
Referred
DISEASE
for CABG.Past Medical History:
HTN
DISEASE
elev. chol.remote fractured sternuminguinal
hernia
DISEASE
carpal tunnel syndrome
DISEASE
PSH
DISEASE
: T&ASocial History:iron workerlives with wifesmoked 2ppd for 20 years quit 15 years ago10-15 beers/weekFamily History:brother with CABG at 39 mother with valvular problemPhysical Exam:HR 78 RR 12 right 122/78 left 120/805'9Admission Date: [**2190-6-24**] Discharge Date: [**2190-7-4**]Date of Birth: [**2134-1-3**] Sex: FService: [**Hospital1 **] MEDICINEHISTORY OF PRESENT ILLNESS: This is a 56-year-old femalewith a history of
rheumatoid arthritis asthma anemia
DISEASE
andstatus post Nissen fundoplication in [**2173**] for severe
gastroesophageal reflux disease
DISEASE
transferred from an outsidehospital for possible embolization of a
GI bleed
DISEASE
. Thepatient first developed black tarry stools two weeks agoprior to admission and an EGD at the time showed a small
ulcer
DISEASE
at the gastroesophageal junction. She received 1 unitof packed red blood cells and was discharged in stablecondition at that time.On [**2190-6-21**] three days prior to admission she againdeveloped black tarry stools. She was scheduled to see Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5656**] her gastroenterologist who performed an EGD on[**2190-6-23**] one day prior to admission. This EGD showed anormal upper GI tract. She was admitted to [**Hospital 1263**] Hospitalthe following day for a colonoscopy which only showed oldblood in the cecum. A repeat upper GI was done and showedtwo clots in the fundus with fresh blood. She wastransferred to the Intensive Care Unit at [**Hospital 1263**] Hospitaland then transferred to the [**Hospital1 188**] for possible angiography and embolization.At time of admission she denied
chest pain
DISEASE
. She had somemild
shortness of breath
DISEASE
especially when standing. She didhave
dizziness
DISEASE
when standing. She also had five stools onthe day of admission with her bowel prep. She had one bowelmovement prior to transfer. She denied
fever cough
DISEASE
or
hematemesis
DISEASE
.PAST MEDICAL HISTORY:1. Nissen fundoplication in [**2173**] for severe
gastroesophageal
reflux disease
DISEASE
.2. Asthma.3.
Rheumatoid arthritis
DISEASE
on Arava methotrexate and Enbrel.4. Bilateral knee replacements in [**2186**].5. L5-S1 laminectomies.6. Iron deficiency
anemia
DISEASE
.7.
Depression
DISEASE
.8. Status post splenectomy.MEDICATIONS AT HOME:1. Arava 20 mg q day.2. Methotrexate 25 mg q week.3. Enbrel 25 mg 2x/week.4. Prednisone 10 q day which was discontinued in [**2190-2-16**].5. Prozac 20 q day.6. Doxepin 100 q day.7. Folate 2 q day.8. Premarin 0.3 q day.9. Medroxyprogesterone 2.75 q day.10. Protonix 40 [**Hospital1 **].ALLERGIES:1. Penicillin which lead to
wheezing
DISEASE
and
shortness of breath
DISEASE
and
itching rash
DISEASE
.2. Sulfa which causes hives.FAMILY HISTORY: Her maternal grandfather had a history of
stomach cancer
DISEASE
and sister with severe
gastroesophageal
reflux disease
DISEASE
. Her father had
gastroesophageal reflux
DISEASE
disease.SOCIAL HISTORY: She denies tobacco alcohol or IV drug use.She is a retired finance worker. She is married with fourchildren.REVIEW OF SYSTEMS: As noted above.PHYSICAL EXAMINATION: On admission she was afebrile with atemperature of 98.7 blood pressure was 103/54 with a heartrate of 100 and oxygen saturation of 97% on room air. Ingeneral she was in no acute distress and pale appearingwoman who is obese. Her head and neck examination: Pupilsare equal round and reactive to light and accommodation.Extraocular motions were intact. Her neck was supple with no
lymphadenopathy
DISEASE
. Her heart was regular rate and rhythmwith a
systolic ejection murmur
DISEASE
loudest at the left uppersternal border. Her lungs are clear to auscultationbilaterally. Abdomen was soft with no
active bowel sounds
DISEASE
nontender nondistended and no
hepatosplenomegaly
DISEASE
. Herextremities were warm and well perfused with no clubbing
cyanosis
DISEASE
or
edema
DISEASE
.LABORATORIES ON ADMISSION: From outside hospital included awhite count of 5.9 hematocrit of 27.7 platelets of 309000.Her electrolytes were a sodium of 141 potassium of 4.6chloride of 104 bicarbonate of 30 BUN 12 creatinine 0.6glucose 121 calcium 8.4 phosphorus 2.6 magnesium 1.9. Hercoagulation panel included a PT of 12 INR of 1.1 PTT of25.4.HOSPITAL COURSE BY PROBLEM:1. Upper
GI bleed
DISEASE
: The patient was transferred to theMedical Intensive Care Unit upon admission and was managedexpectantly for any potential
bleeding
DISEASE
. She was transfused 2units of packed red blood cells and evaluated by theGastroenterology Service. They felt that she would benefitfrom another esophagogastroduodenoscopy prior to angiographyto further evaluate the possible sources of
bleeding
DISEASE
. Shecontinued with stable vitals and her EGD showed no active
bleeding
DISEASE
source or abnormality in the esophagus stomach orduodenum.She was continued on observation in the Medical IntensiveCare Unit until her third hospital day where it was feltthat she was stable to return to the Medical floor. In thefollowing morning however she had a further episode ofblack stool as well as
dizziness
DISEASE
upon standing and
tachycardia
DISEASE
on standing. She was thus taken to theAngiography Vascular Interventional Suite where a leftgastric artery embolization was performed with gelfoam.Please see full report for details of the procedure. Thepatient tolerated the procedure well with some residual
nausea
DISEASE
and
vomiting
DISEASE
for which she was returned to theMedical Intensive Care Unit postoperatively for expectantmanagement.The patient also had one episode of
chest pain
DISEASE
during theprocedure that was evaluated with an electrocardiogram andone set of cardiac enzymes which were both negative for anyevidence of
ischemia
DISEASE
. It was felt that this was likelysecondary to her
gastroesophageal reflux disease
DISEASE
from ahorizontal position.On hospital day seven the patient was again returned to theMedical floor after a stable time in the Intensive Care Unit.She had received 1 unit of packed red blood cells prior toand during the angiography procedure. Her hematocritfollowing this transfusion was 35.2.For the remainder of her hospital stay the hematocritdrifted slightly down to 33 with several small episodes of
melena
DISEASE
. She was continually followed by the GastroenterologyService with repeated hematocrits all remaining within thestable range. Her
dizziness
DISEASE
and
tachycardia
DISEASE
upon standingresolved and no further blood transfusions were necessary.Her
nausea
DISEASE
and
vomiting
DISEASE
resolved after her first dayfollowing the procedure and no further evidence of
bleed
DISEASE
wasnoted. Her diet was advanced slowly from clear liquids 48hours after her embolization procedure and she was advancedto soft solids followed by a regular diet on the day prior todischarge. She remained
pain
DISEASE
free with stable vitals and nofurther evidence of
bleed
DISEASE
on hospital day 11 the day of herdischarge.2.
Shortness of breath
DISEASE
and
hypoxia
DISEASE
: The patient reported
shortness of breath
DISEASE
and
hypoxia
DISEASE
that was thought to besecondary to her
anemia
DISEASE
and deconditioning with decreasedactivity over the prior months. However given the patient'schanges in volume with transfusions as well as her lowerextremity
edema
DISEASE
and presence of murmur an echocardiogram wasobtained which showed normal left ventricular function andejection fraction as well as no evidence of diastolicdysfunction. Please see full report for details of thestudy.In addition given her hospitalizations and partialcompliance with Venodynes sequential compression deviceboots it was felt that a
pulmonary embolism
DISEASE
was also apossible cause for her
shortness of breath
DISEASE
. A CT angiogramwas obtained and no evidence of
pulmonary embolism
DISEASE
wasfound. The patient remained on oxygen 2 liters nasal cannuladuring her early hospitalization however on the final threedays of her hospitalization she was oxygenating 94% on roomair range. She was also able to ambulate without
shortness
DISEASE
of breath or
desaturation
DISEASE
. It was felt that her
hypoxia
DISEASE
waspossibly secondary to her history of asthma/reactive airwaysdisease. Further workup as an outpatient is recommended asneeded.3.
Rheumatoid arthritis
DISEASE
: The patient's
rheumatoid arthritis
DISEASE
medicines were held during this initial acute episode. Sheremained without
pain
DISEASE
or flare of her
rheumatoid arthritis
DISEASE
however on the final hospital day she complained of somemild joint symptoms in her hands. It was recommended thatshe resume her
rheumatoid arthritis
DISEASE
medicines underconsultation of her primary doctor.4.
Depression
DISEASE
and
anxiety
DISEASE
: The patient was maintained on herregimen of Prozac and doxepin as well as receiving Ativan prnand at hs.5.
Fever
DISEASE
: The patient had one episode of
fever
DISEASE
following herGI embolization. This was felt to be secondary topostoperative response to foreign material within thevasculature. Her right groin sites where the interventionalcatheters were placed showed no signs of
infection
DISEASE
. Inaddition her lungs were clear and no urinary symptoms wereidentified. She persisted with some mild low-grade
fevers
DISEASE
for two days following the procedure however thetemperature came down to within her normal rangesubsequently. No sign of
infection
DISEASE
was noted and bloodcultures were not sent.On hospital day 11 the patient was deemed in stablecondition to return home.CONDITION ON DISCHARGE: Good and stable.DISCHARGE STATUS: Home with no services.DISCHARGE DIAGNOSES:1.
Gastrointestinal bleed
DISEASE
.2.
Rheumatoid arthritis
DISEASE
.3. Anxiety/depression.4.
Blood loss anemia
DISEASE
.5.
Hypovolemia
DISEASE
.6. Hypoxia.DISCHARGE MEDICATIONS:1. Arava 20 mg q day.2. Methotrexate 25 mg q week.3. Enbrel 25 mg 2x/week.4. Prednisone 10 q day which was discontinued in [**2190-2-16**].5. Prozac 20 q day.6. Doxepin 100 q day.7. Folate 2 q day.8. Premarin 0.3 q day.9. Medroxyprogesterone 2.75 q day.10. Protonix 40 [**Hospital1 **].11. Omeprazole 40 mg po bid.FOLLOW-UP PLANS: The patient is instructed to followup withher gastroenterologist Dr. [**First Name (STitle) 5656**]. Is instructed to returnto the Emergency Department or contact her physician if shedevelops any further
bleeding
DISEASE
per
rectum dark tarry
DISEASE
stoolsor
fevers nausea
DISEASE
is uncontrolled or
vomiting
DISEASE
. [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**] M.D. [**MD Number(1) 4521**]Dictated By:[**Last Name (NamePattern1) 5657**]MEDQUIST36D: [**2190-7-5**] 16:35T: [**2190-7-7**] 08:32JOB#: [**Job Number 5658**]Admission Date: [**2155-8-3**] Discharge Date: [**2155-8-17**]Date of Birth: [**2090-9-8**] Sex: MService: CSURG
Allergies
DISEASE
:Atenolol / Vasotec / ShellfishAttending:[**First Name3 (LF) 1283**]Chief Complaint:SOBMajor Surgical or Invasive Procedure:redo
AVR/MVR
DISEASE
History of Present Illness:This is a 64yo M who presented with c/o progressive SOB for 6weeks. He has documented significant dysfunction of
AV
DISEASE
over thepast year with planned AVR and possible MVR (not scheduledyet). Presents with 6 weeks of progressive
dyspnea
DISEASE
with acuteworsening over past 24 hrs. New
orthopnea
DISEASE
. No CP. Mild
failure
DISEASE
on CXRPast Medical History:1.Hypercholesterolemia2.3V CABG [**2144**]3.Endocarditis s/p Bioprosthetic in 96AVR4.HTN5.DM-26.Gout7.Carotid Stenosis- 40-50% stenosis of R carotid artery in 978.Renal Artery Occlusion
9.Toxic Thyroid Nodule
DISEASE
s/p
RAI
DISEASE
10.trigger finger release[**2144**]: IPMI [**2144**] CABG with LIMA to LAD [**Year (4 digits) 5659**] to OM1 and OM2[**11/2147**]:
endocarditis
DISEASE
[**2148-2-9**] cardiac catheterization [**Hospital1 18**] for
exertional
DISEASE
armdiscomfort (similar to
pre-bypass angina
DISEASE
). Widely patent bypassgrafts/native 3vd. Moderate-severe MR [**First Name (Titles) **] [**Last Name (Titles) **] moderate to severe
diastolic dysfunction
DISEASE
.[**2148-2-14**] right
retinal artery occlusion
DISEASE
possibly due to aorticvalve associated
embolic event
DISEASE
.[**2148-3-4**]: AVR [**Hospital6 **][**2155-6-17**]: Ruled out for PE. Troponin 0.14. CK'sflat. Diagnosed with
CHF captopril
DISEASE
initiated. Diuresed.[**2154-6-17**] echo: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5660**]
dilated RA
DISEASE
mildly dilated mildsymmetric
LVH
DISEASE
. Aortic root ascending aorta and arch mildlydilated. 1Admission Date: [**2164-7-5**] Discharge Date: [**2164-7-11**]Date of Birth: [**2110-9-19**] Sex: MService: CSUHISTORY OF PRESENT ILLNESS: This is a 51 year old malepatient who noticed to have chest pressure a few hours priorto admission. He presented to an outside hospital EmergencyDepartment about 3:00 in the afternoon and was found to haveelevated ST segments. He was started on Integrilin at thattime and was transferred to [**Hospital1 188**] for emergency cardiac catheterization. This revealedleft main and severe three
vessel coronary artery disease
DISEASE
with a left ventricular ejection fraction of greater than 55percent and was referred for emergency coronary artery bypassgrafting.PAST MEDICAL HISTORY: Significant for
nephrolithiasis
DISEASE
statuspost stone extraction as well as ankle surgery.PREOPERATIVE MEDICATIONS: Accupril Metoprolol 100 mg pobid Lipitor 20 mg po q d Vitamin E and Aspirin daily.ALLERGIES: The patient states no known drug
allergies
DISEASE
although he does note an upset stomach with erythromycin.PHYSICAL EXAMINATION: Upon admission to the hospital wasunremarkable as were his laboratory values with the exceptionof elevated CPKs and Troponins.HOSPITAL COURSE: The patient was taken emergently to theOperating Room due to his findings in catheterizationlaboratory of a 95 percent left main coronary arterystenosis as well as a 90 percent to 95 percent left anteriordescending coronary artery lesion. 80 percent proximal leftcircumflex and an occluded right coronary artery. Thepatient was taken to the Operating Room with Dr. [**First Name8 (NamePattern2) **][**Last Name (NamePattern1) 70**] where he underwent coronary artery bypass grafttimes three. The patient had an intraaortic balloon pumpplaced preoperatively due to his anatomy. Postoperatively hewas transported from the Operating Room to Cardiac SurgeryRecovery Unit in good condition on Propofol and Phenylephrinedrips.On postoperative day #1 he was weaned from mechanicalventilation successfully extubated. He remains on Neo-Synephrine for the next day or so due to some
hypotension
DISEASE
his cardiac function remained good with a cardiac index ofgreater than 3. His intraaortic balloon pump was weaned andsubsequently discontinued on postoperative day #1. Thepatient did require some intravenous fluid boluses for
hypotension
DISEASE
.On postoperative day #2 the patient had some atrial
fibrillation
DISEASE
and was placed on Amiodarone because of this.He was also begun on Lopressor at that time and begun withdiuresis.The following day the patient had converted back to normalsinus rhythm. Had remained hemodynamically stable. Had hisNeo-Synephrine drip weaned to off and was tolerating betablocker and diuresis.Postoperative day #3 he was transferred from the intensivecare unit to the telemetry floor. His Metoprolol had beenincreased. His [**Location (un) 1661**]-[**Location (un) 1662**] drain in his leg had beenremoved and he had begun ambulation and cardiacrehabilitation. The patient subsequently on the telemetryfloor had another episode of
atrial fibrillation
DISEASE
that wasshort lived on [**2164-7-10**] early in the morning that wasself limiting. His Lopressor was increased and he has nothad any further episodes of
atrial fibrillation
DISEASE
. He remainson Amiodarone and Metoprolol for this.PHYSICAL EXAMINATION: Today [**2164-7-11**] is as follows:The patient is afebrile. He is in normal sinus rhythm with arate in the mid 70's. His blood pressure is 120/74. Roomair oxygen saturation is 96 percent. Neurologically he isgrossly intact with no apparent deficits. His pulmonaryexamination - his lungs are clear to auscultationbilaterally. Coronary examination is regular rate andrhythm. His abdomen is soft nontender nondistended. Hisextremities are warm without
edema
DISEASE
. His sternal incision aswell as his right leg incisions are all clean and dry with no
erythema
DISEASE
no drainage. The Steri-strips are intact.DISCHARGE MEDICATIONS: Lopressor 100 mg po bid Lasix 20 mgpo bid times seven days Potassium Chloride 20 mEq po bidtimes seven days Zantac 150 mg po bid Aspirin 325 mg po qd Plavix 75 mg po q d times three months. Lipitor 20 mg poq d Percocet 5/325 po q four hours prn
pain
DISEASE
. The patient isalso to continue on Amiodarone 400 mg po tid times one weekthen decrease to 400 mg po bid times one week then decrease400 mg po q d times one week and then decrease to 200 mg poq d for the remaining week. This is the tentative plan forAmiodarone loading unless it is altered or until it isdiscontinued by the patient's primary cardiologist Dr.[**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]. The patient is also going home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] ofHearts cardiac monitor for his Amiodarone loading and thiswill be transmitted to the electrophysiology service here at[**Hospital1 69**].CONDITION ON DISCHARGE: Good.The patient is to follow up with is primary care physician[**Last Name (NamePattern4) **]. [**Last Name (STitle) 5661**] in one to two weeks. He is to follow up with hisprimary cardiologist Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] also in one to twoweeks and to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] inapproximately five to six weeks.CONDITION ON DISCHARGE: Good.DISCHARGE DIAGNOSES:1.
Coronary artery disease
DISEASE
status post emergent coronary artery bypass graft.2. Postoperative
atrial fibrillation
DISEASE
. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**] [**MD Number(1) 5663**]Dictated By:[**Last Name (NamePattern1) 5664**]MEDQUIST36D: [**2164-7-11**] 12:35:25T: [**2164-7-11**] 14:43:03Job#: [**Job Number 5665**]Admission Date: [**2164-2-15**] Discharge Date: [**2164-2-23**]Date of Birth: [**2117-3-9**] Sex: FService: [**Last Name (un) **]ADMISSION DIAGNOSIS: Colorectal metastases to the liver.PROCEDURES PERFORMED:1. She had a right hepatic lobectomy.2. CT angiography of the chest to rule out a PE.DETAILS OF HOSPITAL COURSE: Ms. [**Known lastname 2643**] is a 47 year oldfemale who presented with synchronous
colorectal metastases
DISEASE
to the liver from a colonic primary. She underwent a colonicresection in the fall of [**2162**]. Underwent chemotherapy whichresulted in a substantial reduction in the
tumor
DISEASE
volume andthe liver. After completing her chemotherapy course andpreoperative work up including a chest CT and PET scan shewas believed resectable.She was taken to the operating room on [**2164-2-15**] whereshe underwent a right hepatic lobectomy. The procedure wasuncomplicated. She spent 1 day in the intensive care unit andwas transferred to the floor.On postoperative day #4 she developed a marked
hypoxia
DISEASE
and
tachycardia
DISEASE
. Was transferred back to the surgical intensivecare unit where she underwent work up for a pulmonaryembolus. No embolus was identified. Chest x-ray wasunremarkable. Over the next 24 hours her oxygen requirementdecreased and she was transferred back to the floor. Hospitalstay was unremarkable. The pathology report demonstrated noresidual
tumor
DISEASE
within the liver specimen.She was discharged home on [**2164-2-23**]. She will follow upwith Dr. [**First Name (STitle) **] in 1 week. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **] [**MD Number(1) 3432**]Dictated By:[**Last Name (NamePattern4) 3433**]MEDQUIST36D: [**2164-4-2**] 07:19:44T: [**2164-4-2**] 07:42:15Job#: [**Job Number 5666**]Admission Date: [**2101-12-17**] Discharge Date: [**2101-12-22**]Date of Birth: [**2045-5-15**] Sex: MService: PLASTIC
Allergies
DISEASE
:NovocainAttending:[**First Name3 (LF) 5667**]Chief Complaint:left multidigit
trauma
DISEASE
s/p table saw injuryMajor Surgical or Invasive Procedure:1. left index digital artery digital nerve repair radial andulnar nerve repair x22. radial lateral collateral ligament repair3. left long finger radial digital artery repair4. left long finger digital artery digital nerve radial andulnar repair x25. left long finger flexor digitorum profundus repair6. left ring finger radial digital artery repair withmicrovascular anastomosis7. left ring finger radial and ulnar digital nerve repair x28. left ring finger flexor digitorum profundus repair9. A1 pulley release10. repair of lacerations 20-cm11. dissection of dorsal vein for vein graft harvestHistory of Present Illness:56yo male right-hand dominant OSH transfer with
traumatic injury
DISEASE
to left hand with table saw at approximately 1230p today.Patient states hand slipped and was caught by table saw.Immediately after the incident patient reports moderate
pain
DISEASE
and placed clenched injured hand in right hand and proceeded toemergency department. Patient notes general
numbness
DISEASE
of digits[**1-26**] and inability to flex digit 4. Patient received cefazolinand
tetanus
DISEASE
booster at outside hospital.Past Medical History:MI ([**2081**])
hyperlipidemia
DISEASE
GERD
nephrotic syndrome
DISEASE
pneumothorax
DISEASE
Social History:works as commercial drivertob - 2pk/day prev 4pk/dayEtOH - socialillicit - deniesFamily History:non-contributoryPhysical Exam:upon admission:General - AOx3 NADChest - CTABCV - RRR S1/S2 appreciatedAbd - soft nontender nondistendedExtremity - left upper extremity: patient with significantmultiple injuries of the hand as follows.1st digit: laceration of the volar aspect along the MCP noexposed tendonAdmission Date: [**2190-3-8**] Discharge Date: [**2190-3-16**]Date of Birth: [**2107-11-21**] Sex: MService: MEDICINE
Allergies
DISEASE
:Heparin AgentsAttending:[**First Name3 (LF) 3984**]Chief Complaint:
dyspnea
DISEASE
Major Surgical or Invasive Procedure:N-G tube placementHistory of Present Illness:Mr. [**Known lastname **] is an 82 yo male s/p prolonged hospital andrehabilitation course following XRT for [**Location (un) 5668**] cell carcinomawho presents with acute onset
shortness of breath
DISEASE
at [**Hospital 100**]Rehab earlier today. Per report oxygen saturation dropped to84-85% on 4L NC from baseline in the mid 90's. He was
hypotensive
DISEASE
with SBP's in the 80's which resolved with IVF. Perreport from [**Hospital 100**] Rehab patient was noted to have new thickbrown sputum with difficulty swallowing. He was recently startedon levofloxacin/flagyl three days ago for treatment of apresumed aspiration
pneumonia
DISEASE
..Of note he was admitted to NEBH in [**Month (only) 1096**] for Admission Date: [**2149-10-15**] Discharge Date: [**2149-10-20**]Date of Birth: [**2083-9-18**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Niaspan Extended-ReleaseAttending:[**First Name3 (LF) 1406**]Chief Complaint:
Exertional chest heaviness
DISEASE
Major Surgical or Invasive Procedure:[**2149-10-15**] Coronary artery bypass grafting x4 with the leftinternal mammary artery to left anterior descending artery andreverse saphenous vein grafts to the distal right coronaryartery first and second obtuse marginal arteries.History of Present Illness:66 year old male with a 2 week history of
chest burning
DISEASE
whichoccurs about 10-15 minutes into his daily 1 mile walk. It lastsfor 20-30 seconds and then resolves and he is able to finishwalking his mile. He notes that he does not get the symptomseverytime he walks. He denies any symptoms at rest. He does notewaking up with bilateral ankle/feet pain/throbbing at night. Hewas referred for a cardiac catheterization and was found to have
coronary artery disease
DISEASE
. He is now being referred to cardiacsurgery for revascularization.Past Medical History:
Diabetes Type II
DISEASE
Hypertension
DISEASE
Hyperlipidemia
DISEASE
Osteoarthritis
DISEASE
Lumbar
disc disease
DISEASE
Proteinuria
DISEASE
Polyps
DISEASE
on colonoscopys/p left knee scope x 4Social History:Race:CaucasianLast Dental Exam: 10 years agoLives with:WifeContact:[**Name (NI) 4457**] (wife) Phone #[**Telephone/Fax (1) 5671**]Occupation:retiredCigarettes: Smoked no [x] yes []Other Tobacco use:deniesETOH: deniesIllicit drug use:deniesFamily History:
Premature coronary artery disease
DISEASE
- uncle had aheart transplant in his early 50's. Father had 3 MI's first inhis 40's. Brother had CABG at age 59.Physical Exam:Pulse:60 Resp:16 O2 sat:100/RAB/P Right:168/87 Left:179/80Height:5'8Admission Date: [**2175-3-12**] Discharge Date: [**2175-3-24**]Date of Birth: [**2105-11-5**] Sex: MService: NEUROSURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 78**]Chief Complaint:Progressive
lethargy
DISEASE
and collapseMajor Surgical or Invasive Procedure:
ACA aneursym
DISEASE
coilingHistory of Present Illness:HPI: This is a 69 year old male who is primarily Russianspeakingwho was reportedly outside fishing when he slipped and fell.Henow presents to the ED with his wife who reports that he hasbecome progressively lethargic today. The patient is unable toreport a review of systems due to his
lethargy
DISEASE
. Upon seeing thepatient we recommended an emergent CTA.Past Medical History:PMHx:
spondylosis
DISEASE
chronic low back
pain
DISEASE
associated withdegenerative changes. Followed by Dr. [**Last Name (STitle) 79**] for
prostate cancer
DISEASE
.
Chronic lymphocytic leukemia
DISEASE
which has been very stable.Social History:Lives with WifeFamily History:NCPhysical Exam:On Admition:Gen: lethargic atraumaticHEENT: Pupils: PERRL 4-mm EOMs pt not participating in examNeuro:Mental status: opens eyes to stimulation lethargic.Orientation: not answering questions but following simplecommandsLanguage:pt lethargic/non verbal at time of exam and emergentlybrought to CTA-Cranial Nerves:I: Not testedII: Pupils equally round and reactive to light 4 to 3mm bilaterally. Visual fields- not testedIII IV VI: Extraocular movements- not testedV VII: Facial strength and sensation intact and symmetric.VIII: [**Name (NI) 80**] pt did not participateIX X: Palatal elevation- pt did not participate[**Doctor First Name 81**]: Sternocleidomastoid and trapezius- pt did not participateXII: [**Name (NI) 82**] pt did not participate.Motor: Normal bulk and tone bilaterally. No
abnormal movements
DISEASE
tremors
DISEASE
. Strength appears full pt grips with bilat hands [**5-9**]lifts all extremities off the bed to commandSensation: Intact to light touch proprioception pinprick andvibration bilaterally.Toes downgoing bilaterallyCoordination: pt too lethargic to performPertinent Results:CT head:Extensive bilateral
subarachnoid hemorrhage
DISEASE
. Recommend head CTAto evaluate for an
intracranial aneurysm
DISEASE
.Findings were discussed with Dr.CTA:FINDINGS: There is a 3 mm x 3 mm saccular outpouching from theregion of the anterior communicating artery (2:317) consistentwith
aneurysm
DISEASE
. This has a very narrow neck and would beamenable to endovascular intervention. No other
aneurysm
DISEASE
or
vascular abnormality
DISEASE
is seen.There is stenosis at the origin of the right vertebral artery.Otherwise the carotid and vertebral arteries and their majorbranches are patent with no evidence of
stenosis
DISEASE
or occlusion.The distal cervical internal carotid arteries measure 5 mm onthe right and 5 mm on the left.Mild-to-moderate multilevel
cervical spine degenerative
DISEASE
changesare noted.IMPRESSION: 3 mm
saccular aneurysm
DISEASE
arising from the anteriorcommunicatingartery with narrow neck.Brief Hospital Course:Mr. [**Known lastname 83**] was admited on [**2175-3-12**] and became increasinglylethargic and transferred to the ICU for further care under theNeurosurgery service. A diagnostic CTA revealed a large
ACOM
DISEASE
aneursym which was coiled the following day.Post Coiling the pt. was admitted to the ICU with a ventriculardrain. There were no incidences of increased intracranialpressure or decline. A cerebral perfusion study performed [**3-15**]confirmed the lack of
vasospasm
DISEASE
and develoing
strokes
DISEASE
.He had some R shoulder weakness and shoulder X-ray wasconcerning for rotator cuff injury and orthopedics wasconsulted.On [**2179-3-16**]/14/15 his ventricular drain was clamped and reopeneddue to elevated ICP levels. On [**3-19**] he was transferred to theSDU and continued to remain stable. He had his ventriculardrain clamped on [**3-21**] and after 48 hours of the clamping trialhe had a CT done which was stable without any evidence of
hydrocephalus
DISEASE
. At this time the drain was pulled.He was placed on a fluid restriction for a brief period of timefor a drop in his Na level and also on salt tabs upondischarge to rehab we have removed the fluid restriction but weare continuing the salt tabs we advise that the Na level bechecked every other day and the salt tabs may be d/c'ed when Nais stable on serial checks. Upon discharge his Na is 138.He is now ready for discharge to rehab.On discharge his exam is as follows:Alert and Oriented X2Moving all extremities with full strengthslight Right Drift which has been persistant throughout hishospitalization and possibly secondary to a rotator cuffinjury.Medications on Admission:[**Name (NI) 84**] wifeDischarge Medications:1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times aday).2. Bisacodyl 5 mg Tablet Delayed Release (E.C.) Sig: Two (2)Tablet Delayed Release (E.C.) PO DAILY (Daily).3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2times a day).4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)Injection ASDIR (AS DIRECTED).5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY(Daily).7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2times a day).9. Heparin (Porcine) 5000 unit/mL Solution Sig: One (1)Injection TID (3 times a day).10. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-6**]Tablets PO Q4H (every 4 hours) as needed for
Headaches
DISEASE
.11. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every4 hours): Continue for [**2175-4-2**].Discharge Disposition:Extended CareFacility:[**Hospital6 85**] - [**Location (un) 86**]Discharge Diagnosis:Acom Aneursym
Subarachnoid Hemorrhage
DISEASE
Discharge Condition:StableDischarge Instructions:General InstructionsAdmission Date: [**2117-7-7**] Discharge Date: [**2117-7-12**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2610**]Chief Complaint:
Lightheadedness dizziness
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:[**Age over 90 **] yo M with no prior cardiac hx following p/w 2 day history of
light-headedness weakness sweating dizziness
DISEASE
. Symptomsstarted while he was out for a walk on Monday where he had asudden onset of
lightheadedness
DISEASE
and he had to sit down. Thesymptoms have been continuous since Monday. His son notes thatthe patient is normally very active and independent for ADLs.Patient took some of his neighbor's dizziness medication' whichis believed to be meclizine also took some additional Ambienpossibly 15mg. His denied
chest pain
DISEASE
arm
pain diaphoresis
DISEASE
onadmission.In the ED his initial vitals were 98.9 125/64 106 20 95% on
RA
DISEASE
. EKG showed new
atrial flutter
DISEASE
with varying conduction andold
LBBB
DISEASE
. He received Diltiazem 10mg PO with good HR responseinto 80s. Son describes notable improvement s/p treatment in ED.On arrival to the floor 96.1 128/84 80 20 93% on 2L NC. Hehas no home O2 requirement.At 10pm pt received ambien and 30mg po diltiazem--per nurse hewas in NAD. 30 minutes later he was found
restless
DISEASE
anddiaphoretic with satAdmission Date: [**2184-8-4**] Discharge Date: [**2184-8-10**]Date of Birth: [**2112-1-20**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 106**]Chief Complaint:
Shortness of Breath
DISEASE
Major Surgical or Invasive Procedure:[**2184-8-5**]: Cardiac catheterization no interventionHistory of Present Illness:72 yo F with PMHx of 2vessel CAD s/p RCA atherectomy in '[**67**]
HTN
DISEASE
morbid
obesity Hyperlipidemia
DISEASE
who presents with
dyspnea
DISEASE
x3days worse past day with a
dry cough
DISEASE
. Symptoms startedabruptly on Sunday night with SOB while walking to bathroom. SOBremaind persistent over the following days with worsening DOE.She initially presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5678**] hospital and was found tobe
hypotensive
DISEASE
and was transferred to [**Hospital1 18**] ED with suggesteddiagnosis of PNA incidentally found to have elevated troponinof 1.73. She was started on heparain at OSH. Received azithroand Ceftriaxone at OSH. Was on neo at 100 mcg. Got RIJ in ourED. Crackles at bases
Febrile
DISEASE
to 100.1. Gave levofloxacin. Puton levophed in ED. O2 sat high 90's on 4L. CXR here appears tohave bilateral infiltrates. ECG here afib rate [**Street Address(2) 5679**]elevations V4-V6. Patient denies
chest pain
DISEASE
..On review of systems (limited as pt poor insight) she deniesany prior history of
stroke TIA
DISEASE
deep
venous thrombosis
DISEASE
pulmonary embolism bleeding
DISEASE
at the time of surgery
myalgias
DISEASE
joint pains cough hemoptysis
DISEASE
black stools or red stools. Shedenies recent
fevers chills
DISEASE
or
rigors
DISEASE
..Cardiac review of systems is notable for absence of
chest pain
DISEASE
but worsening
dyspnea
DISEASE
on exertion she endorses unchangedparoxysmal
nocturnal dyspnea
DISEASE
and
nocturia orthopnea
DISEASE
which isunchanged no ankle
edema
DISEASE
no
palpitations
DISEASE
no
syncope
DISEASE
or
presyncope
DISEASE
..Past Medical History:1. CARDIAC RISK FACTORS: Dyslipidemia
Hypertension
DISEASE
2. CARDIAC HISTORY:-PERCUTANEOUS CORONARY INTERVENTIONS: 93 RCA atherectomy3. OTHER PAST MEDICAL HISTORY:
Hypertension
DISEASE
Obesity
DISEASE
Paroxismal
Afib
DISEASE
AsthmaSocial History:Pt lives alone in an atp in [**Location (un) 5680**]. She is very sedentary andis able to function on a routine. She has 2 daughters who livenearby and help her extensively. Will likely need placement at[**Hospital3 **] or other facility after discharge.Family History:No family history of early MI
arrhythmia cardiomyopathies
DISEASE
orsudden cardiac deathAdmission Date: [**2158-9-11**] Discharge Date: [**2158-9-15**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 689**]Chief Complaint:
Failure to thrive acute renal failure mental status
DISEASE
change
tremor
DISEASE
Major Surgical or Invasive Procedure:G-tube placementHistory of Present Illness:86 yo F with
dementia HTN CKD
DISEASE
with recent discharges from[**Hospital1 18**] for FTT
ARF
DISEASE
and
UTI
DISEASE
admitted today from rehab due to poorPO intake and concern of new body tremors/neck spasmAdmission Date: [**2174-9-8**] Discharge Date: [**2174-9-11**]Date of Birth: [**2119-3-4**] Sex: MService: SURGERY
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 2597**]Chief Complaint:acute L leg
ischemia
DISEASE
Major Surgical or Invasive Procedure:Left femoral embolectomy and vein patch angioplasty.History of Present Illness:This 55-year-old gentleman presented to our emergency room lastnight with an acutely ischemic left foot which had been presentfor several hours. He was placed on heparin with significantimprovement in symptoms. He had absent pulses distal to thegroin on the left with intact pulses throughout on the right. Heis now being explored for possible embolectomy.Past Medical History:PMH:MIHIV
HTN
DISEASE
Social History:He denies any use of alcohol or IV drugs. He has smoked [**1-30**]packs of cigarettes per day for the last 30 years.Family History:non contributaryPhysical Exam:HEENT:No thrush. Neck is supple.Full range of motion. No
lymphadenopathy
DISEASE
.CHEST:is clear to auscultation bilaterally.HEART:regular rate and rhythm without gallops or rubs noted. There isa III/VI murmur noted at the left lower sternal border to theleft upper sternal border.ABDOMEN:is soft nontender nondistended. There werebowel sounds noted.RECTAL:There is no stool in the vault. The fluid in the vault is occultblood negative.EXTREMITIES:without
clubbing cyanosis
DISEASE
or
edema
DISEASE
.NUEROLOGICAL EXAMINATION:Awake alert and oriented x3.Cranial nerves motor examination and sensory examination werenormal.The toes were down-going bilaterally.Pertinent Results:[**2174-9-11**]WBC-6.0 RBC-2.66* Hgb-11.9* Hct-31.4* MCV-118* MCH-44.7*MCHC-37.8* RDW-13.4 Plt Ct-184[**2174-9-11**]Plt Ct-184[**2174-9-11**]PT-12.4 PTT-27.7 INR(PT)-1.0[**2174-9-11**]Glucose-93 UreaN-15 Creat-0.9 Na-141 K-4.1 Cl-107 HCO3-27AnGap-11[**2174-9-8**]CK(CPK)-409*[**2174-9-11**]Calcium-8.9 Phos-2.9 Mg-1.7Cardiology Report ECG Study Date of [**2174-9-8**] 11:30:44 AMBaseline artifact. Sinus rhythm. Q waves in the anterior leadsconsistent with prior
infarction
DISEASE
. Probable left atrialabnormality. Compared to the previous tracing of [**2169-3-14**] therate is faster.Intervals AxesRate PR QRS QT/QTc P QRS T64 168 96 [**Telephone/Fax (2) 5693**] 57[**2174-9-8**] 2:07 PMCHEST (PRE-OP PA & LAT)Reason: pt preop vascular surgery[**Hospital 93**] MEDICAL CONDITION:55 year old man with new onset
pain
DISEASE
L leg/blanching and pulsesdiminished. Arterial clotREASON FOR THIS EXAMINATION:pt preop vascular surgeryINDICATION:
Left leg blanching
DISEASE
and decreased pulsespreoperative study for vascular surgery.No studies are available for comparison on PACs.AP UPRIGHT AND LATERAL VIEWS OF THE CHEST: The heart size isnormal. The mediastinal and hilar contours are normal. The lungsare clear. There is no
pleural effusion
DISEASE
or
pneumothorax
DISEASE
. Theosseous structures are unremarkable.IMPRESSION: No evidence of acute cardiopulmonary process.GENERAL URINE INFORMATIONType Color Appear Sp [**Last Name (un) **]Straw Clear 1.008Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH LeuksSM NEG NEG NEG NEG NEG NEG 6.5 NEGRBC WBC Bacteri Yeast Epi0-2 0-2 NONE NONE 0-2Brief Hospital Course:Pt admitted on [**2174-9-11**]Stared on heparin.Pt undergoes a Left femoral embolectomy and vein patchangioplasty. Pt tolerates the procedure well. There were nocomplications. Flow was re-established intothe profunda femoris first and then into the superficial femoralartery. Doppler interrogation demonstrated good flow in bothbranches and there was a strongly palpable dorsalis pedis pulse.Pt extubated in the OR. Pt transfered to the PACU in stablecondition.Once recovered from anesthesia. Pt transfered to the PACU instable condition.Once recovered from anesthesia pt transfered to the VICUinstable condition.IV Heparin started / coumadin started.[**2174-9-12**]Pt delined diet was advanced as tolerated.PT consult was obtained. Pt was allowed to get OOB to chair.[**2174-9-13**] - DischargePt stable PTT was monitered / On Discharge pt INR not at desiredlevel. Pt [**Name (NI) 1788**] on lovenox for bridge over to
couamdin
DISEASE
.On discharge pt is stable / taking PO / ambulating / pos BM /urinating without difficulty.Medications on Admission:lopressor 25'combivirviramunelisinoprillipitoraspirinDischarge Medications:1. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) syringeSubcutaneous once a day: Continue lovenox daily until INR is atleast 2.0.Disp:*30 syringes* Refills:*0*2. Outpatient [**Name (NI) **] WorkPT INR labs every other day until INR is at least 2.0. Pleasehave the [**Name (NI) **] fax the results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD.3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.Disp:*40 Tablet(s)* Refills:*0*4. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO atbedtime.Disp:*30 Tablet(s)* Refills:*6*5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day asneeded for
constipation
DISEASE
.Disp:*60 Capsule(s)* Refills:*0*Discharge Disposition:HomeDischarge Diagnosis:primary diagnosis1)
Thromboembolism
DISEASE
s/p embolectomy and vein patch angioplasty.secondary diagnosis2) HIV3)
HTN
DISEASE
4) h/o MIDischarge Condition:goodDischarge Instructions:Please resume all your home medications as before as well as theones prescribed to you upon discharge from the hospital. If youexperience
fevers chills
DISEASE
leg
pain
DISEASE
or severe
bleeding
DISEASE
fromyour incisions please report to the emergency department.Please do not drive for one week. Please keep your dressing ontill Monday. You may take a shower on Monday. Please do notsoak in baths or swim in pools.Please be careful with falls and bumps because of increased riskof
bleeding
DISEASE
with lovenox and coumadin.Followup Instructions:Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one week to followup your
blood coagulation
DISEASE
times (PT/INR). Please call ([**Telephone/Fax (1) 5694**] to make an appointment. Dr. [**Last Name (STitle) **] will also set upa TTE to evaluate your heart. Thank you.Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks. Pleasecall [**Telephone/Fax (1) 3121**] to make an appointment.Completed by:[**2174-11-1**]Admission Date: [**2174-9-8**] Discharge Date: [**2174-9-11**]Date of Birth: [**2119-3-4**] Sex: MService: VSUCHIEF COMPLAINT: Left leg
ischemia
DISEASE
.HISTORY OF PRESENT ILLNESS: This is a 55 year old gentlemanwith
HIV coronary artery disease
DISEASE
status post myocardial
infarction
DISEASE
who woke up at 1:00 a.m. with an ice cold leftleg from the upper thigh to the foot. He admits to
pain
DISEASE
inthe calf and
numbness
DISEASE
. Symptoms improved by 5:00 a.m. but
pain
DISEASE
continued. The patient went to the emergency room at anoutside hospital at [**Hospital3 417**] Hospital in [**Hospital1 1474**]where he was evaluated. The patient was begun on IV heparinand transferred here for further evaluation and treatment.On arrival to our emergency room vascular service wasconsulted. The patient was admitted to the vascular servicefor definitive care.PAST MEDICAL HISTORY: Allergies to penicillinmanifestations unknown. Illnesses include coronary arterydisease and
myocardial infarction
DISEASE
at the age of 49 statuspost angioplasty. History of HIV. History of
hypertension
DISEASE
.PAST SURGICAL HISTORY: No past surgical history.MEDICATIONS: Lopressor XL 25 mg dailyAdmission Date: [**2179-4-28**] Discharge Date: [**2179-5-3**]Date of Birth: [**2119-3-4**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 922**]Chief Complaint:post
infarction angina
DISEASE
Major Surgical or Invasive Procedure:coronary artery bypass grafts x4(LIMA-LADSVG-DiagSVG-OMSVG-PDA)History of Present Illness:This 60 year old white male developed
chest pain
DISEASE
on [**4-17**]while driving. He was found to be bradycardic in the 40s andwas admitted to [**Hospital3 417**] Hospital and ruled in for
infarction
DISEASE
with a Troponin of 11. Angioplasty and DES wereperformed to the mid right coronary. A stress test wasperformed prior to discharge and was positive with ECG changesand
pain
DISEASE
. He was transferred here after recatheterizationrevealed triple
vessel disease
DISEASE
.Past Medical History:
Coronary artery disease
DISEASE
s/p stents x 2 to left anterior descending
hypertension
DISEASE
HIV positives/p right carotid endarterectomy
peripheral vascular disease
DISEASE
h/o deep
vein thrombophlebitis
DISEASE
Social History:He denies any use of alcohol or IV drugs. He has smoked [**1-30**]packs of cigarettes per day for the last 30 years.Family History:non contributaryPhysical Exam:Admsiision:Pulse: 72 Resp:17 O2 sat: 98% on
RA
DISEASE
B/P Right: Left:Height:5'[**80**]Admission Date: [**2131-9-2**] Discharge Date: [**2131-9-4**]Date of Birth: [**2073-4-29**] Sex: FService: SURGERY
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 668**]Chief Complaint:
abdominal pain
DISEASE
Major Surgical or Invasive Procedure:s/p exploratory laparotomy sigmoid colectomy temporaryabdominal closure [**2131-9-3**]s/p exploratory
lapartomy small bowel
DISEASE
resection temporaryabdominal closure [**2131-9-4**]History of Present Illness:58yoF w/ DMAdmission Date: [**2149-1-24**] Discharge Date: [**2149-2-4**]Date of Birth: [**2087-11-13**] Sex: MService: MedCHIEF COMPLAINT: Gastric varices.HISTORY OF PRESENT ILLNESS: The patient is a 61-year-oldmale with past medical history of
chronic hepatitis B
DISEASE
complicated by
cirrhosis portal hypertension gastric
varices and hepatic encephalopathy
DISEASE
(failed interferon andlamivudine therapy in the past and now on
Hepsera
DISEASE
for
hepatitis B
DISEASE
) initially transferred from [**Hospital3 417**]Hospital on [**2149-1-24**] in preparation for TIPS procedure. Thepatient was admitted to [**Hospital3 417**] Hospital with 1-weekhistory of right-sided
abdominal pain
DISEASE
episode of large
bloody emesis
DISEASE
with clots and positive melena. EGD on[**2149-1-13**] at the outside hospital revealed large gastricvarices with dark blood in the stomach and duodenum but no
active bleeding
DISEASE
. On [**2149-1-22**] the patient became obtundedand was given octreotide drip and lactulose for hepatic
encephalopathy
DISEASE
. Surgery was consulted who recommended TIPS.The patient was then transferred to [**Hospital1 18**] MICU and wassomnolent on arrival. EGD performed on [**2149-1-25**] showed no
esophageal varices 2 erosions
DISEASE
in the antrum with cleanbases no recent
bleed
DISEASE
appearance consistent with portalgastropathyAdmission Date: [**2149-7-30**] Discharge Date: [**2149-8-5**]Date of Birth: [**2087-11-13**] Sex: MService: MEDICINE
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 3984**]Chief Complaint:
Confusion
DISEASE
&
agitation
DISEASE
Major Surgical or Invasive Procedure:Endotracheal intubationCentral venous line & arterial line placementEEGHistory of Present Illness: 61yo male with
HBV cirrhosis
DISEASE
complicated by portal
HTN
DISEASE
gastric varicies and s/p TIPS who was transferred to [**Hospital1 18**] fromoutside facility for
confusion
DISEASE
&
agitation
DISEASE
. He was also notedto be
jaundiced
DISEASE
with
asterixis
DISEASE
. Pt had also sustained a fallwith
facial trauma
DISEASE
several weeks ago. In the ED he desaturated to 80% on 6L/NC and was found tohave EKG evidence of an acute anterior MI. He was intubated forairway protection & seen by cardiology. He had an emergent ECHOwhich demonstrated an EF of 40-50%. He was felt to be too highrisk for anticoagulation or catheterization and was treatedmedically with beta-blocker aspirin and plavix. He alsoreceived a chest CTA to evaluate a widened mediastinum & LLLconsolidation prior to transfer to MICU.Past Medical History:HBV with
cirrhosis
DISEASE
Portal
hypertension
DISEASE
Gastric variciess/p TIPS [**1-/2149**]
Hepatic encephalopathy
DISEASE
HPV
Gastroparesis
DISEASE
Diverticulosis
DISEASE
s/p partial colectomys/p cholecystectomy
Hypothyroidism
DISEASE
Liver hemangioma
DISEASE
s/p radiofreq-ablations/p R knee surgerySocial History:Lives with partner.Worked as a volunteer Admission Date: [**2114-3-26**] Discharge Date: [**2114-4-19**]Date of Birth: [**2037-3-25**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 165**]Chief Complaint:
constipation
DISEASE
w/ inability to void- developed
chest pain
DISEASE
in ERMajor Surgical or Invasive Procedure:[**2114-4-2**] urgent CABG x2 (LIMA to LAD SVG to PDA)[**2114-4-11**] PEG[**2114-4-16**] TrachHistory of Present Illness:76M h/o
Diabetes HTN hypercholesterolemia
DISEASE
h/o
CVA
DISEASE
elevatedPSA on warfarin arrives with 5 days of inability to void and7day h/o
constipation
DISEASE
. Poor historian with reported poor followup history in chart and unclear about what meds he takes athome. Tried suppositories and laxatives without effect initiallybut then states that he had small BM yesterday at home. Lastcolonoscopy was over 10 yrs ago per pt. Arrived in ED because hestates Dr. [**Last Name (STitle) 5717**] was not in office - he mainly arrives with c/ourinary retention. Of note it appears that he was on flomax inpast and has been referred to urology for w/u with elevated PSAaround 6 but he states he is no longer taking this med. He alsofailed to f/u with urology for prostate bx. Denies abd
pain
DISEASE
n/v or any other sx.In ED vitals were 98.8 57 124/61 16 97%
RA
DISEASE
. KUB consistantwith
constipation
DISEASE
no stool in rectum. Foley was placed andurine relieved. Given enema with another small BM pt statesthat now his bowels are relieved. Labs notable for Cr 1.5(baseline 1.1) Na slightly elevated to 146 c/w
dehydration
DISEASE
. Ontransfer from ED to floor pt was comfortable without
pain
DISEASE
andonly concerned for urinary retention.During the course of his hospitalization he experienced chest
pain
DISEASE
and
shortness of breath
DISEASE
. His
pain
DISEASE
was reported to radiatefrom to his throat and resolved with sublingual nitroglycerinand oxygen administration. ECG demonstrated LBBB with ST
depressions
DISEASE
in II and AVF which resolved. CE Tn 0.02 -Admission Date: [**2199-1-22**] Discharge Date: [**2199-2-12**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 99**]Chief Complaint:
hypernatremia
DISEASE
unresponsivenessMajor Surgical or Invasive Procedure:PEG/trachHistory of Present Illness:[**Age over 90 **]yo F with history of
dementia diabetes mellitus
DISEASE
hypertension CVA
DISEASE
Russian speaking woman who was foundunresponsive at [**Hospital 100**] Rehab. On [**2199-1-21**] she was noted to havedifficulty in swallowing. She was placed on NC for 88%RA. Onmorning of [**2199-1-22**] she desaturated to low 90s on 5 L. She wasthen noted to be unresponsive with left eye sluggish rightfaical droop right arm flaccid mottled right extremities andvitals 118/68 P104 RR40 T 99.8 and 90% on 5L.In ED patient found to be
hypernatremic
DISEASE
and recieved 2L of NS.CXR was concerning for RLL PNA and she was started onlevo/flagyl. She was also reported to be more lethargic in thepast 1-2 weeks.Per PCP [**Name10 (NameIs) **] baseline 1 week ago she has been sitting up in thechair pleasantly demented but interactive.Past Medical History:1. [**2198-11-16**] PRIF of left distal femur
fracture
DISEASE
with [**Last Name (un) 101**]plate(require 4 person lift followed by ortho clinic)2. [**8-21**]:ORIF of right intreathrochanteric hip
fracture
DISEASE
3.
osteoporosis
DISEASE
4.
CVA
DISEASE
in [**2189**]5.
hypertension
DISEASE
6.
dementia
DISEASE
7.
diabetes mellitus-diet
DISEASE
controlled8. h/o
meningioma
DISEASE
9. history of falls10.
cataracts
DISEASE
Dementia
DISEASE
DM
DISEASE
hypertension
DISEASE
CVA
DISEASE
Social History:TOB-deniesETOH-deniesFamily History:lives at [**Hospital3 102**]Physical Exam:T97.3 P88 BP112/32 NSRon
NRB
DISEASE
100%Gen-elderly woman NAD pale and lethargicneuro-arousable groans in response to
pain
DISEASE
non-conversationalcannot assess orientation cannot assess other neuro examCV-faint heart sounds RRRresp-rhonchi diffusely no crackles no accessory muscle use[**Last Name (un) 103**]-no BS soft
NT/ND
DISEASE
no HSMskin-stage 2
decubitus ulcer
DISEASE
at coccyx regionPertinent Results:CT head [**2199-1-22**]:No evidence of acute
intracranial hemorrhage
DISEASE
or major corticalterritorial infarction.CXR [**2199-1-22**]:: New right lower lobe confluent
opacity
DISEASE
which may represent adeveloping area of
pneumonia
DISEASE
. Differential diagnosis includesaspiration and
atelectasis
DISEASE
. Dedicated PA and lateral chest radiograph issuggested for morecomplete characterization when the patient's condition permits.no contrast head CT [**2199-1-28**] FINDINGS: There has been interval development of an area ofdecreased attenuation at the left basal ganglia andperiventricular white matter in the distribution of the leftlenticulostriate artery consistent with a subacute
infarct
DISEASE
.There is associated
swelling
DISEASE
with mass effect on the leftlateral ventricle. There is no shift of normally midlinestructures. Additional areas of
hypodensity
DISEASE
in theperiventricular white matter and right centrum semiovale areunchanged and consistent with old
infarctions
DISEASE
. Two calcified
meningiomas
DISEASE
are again seen arising at the left frontal dura andanterior olfactory groove. They are unchanged from prior study.No
intracranial hemorrhage
DISEASE
was identified. Surrounding osseousand soft-tissue structures are unremarkable.IMPRESSION: Subacute left lenticulostriate infarction which wasnot present on head CT of [**2199-1-22**]echo [**2199-1-28**]:The left atrium is normal in size. There is mild symmetric leftventricular hypertrophy. The left ventricular cavity size isnormal. Due to suboptimal technical quality a focal wallmotion abnormality cannot be fully excluded. Overall leftventricular systolic function is normal (LVEFAdmission Date: [**2183-10-11**] Discharge Date: [**2183-10-24**]Date of Birth: [**2128-1-16**] Sex: MService: MEDICINE
Allergies
DISEASE
:SudafedAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:
Hemoptysis
DISEASE
Major Surgical or Invasive Procedure:Bronchoscopy on [**2183-10-11**] and [**2183-10-17**][**2183-10-11**]: IR embolization of an intercostal/bronchial arterytrunksupplying the right lower lobe.[**2183-10-13**] IR Successful embolization of right bronchial artery[**2183-10-15**]: IR embolization of two right intercostal arteriessupplying lung parenchymaIntubationPICC lineHistory of Present Illness:Mr. [**Known lastname 5721**] is a 55yo M with history of
NSCLC
DISEASE
s/p chemo XRTand surgery in [**2178**] with post-rad pulm
fibrosis bronchiectasis
DISEASE
and
emphysema
DISEASE
who presented with
hemoptysis
DISEASE
. He developed a
cough
DISEASE
with frank blood two days prior to admission andpresented to an OSH for evaluation. There he had stable vitalsigns and hematocrit and had a CTA which showed bilateral lowerlobe ground glass
opacities pulmonary herosiderosis
DISEASE
vs.atypical PNA. Patient refused ambulance transfer to [**Hospital1 18**] andpresented to our ED this AM..In the ED initial vs were: 98.8 103 122/100 20 100%.Patient was given ativan for
anxiety
DISEASE
approximately one liter ofNS and continued on levaquin which was started on [**10-10**] by hisoncologist. Thoracics was consulted and recommended discussinghis case with IP for possible bronch. Patient had witnessed
hemoptysis
DISEASE
of approximately 200cc of frank blood in the ED andhas 4 units crossed. His hematocrit and vitals were stable withSBP in the 120s and heart rate in the 90s-100s. His EKG wasunremarkable. Thoracics wants on west for OR access ifnecessary possibly bronch tomorrow or monday. Had 100-200cc
hemoptysis
DISEASE
here and once at home today. 3 total episodes oflarge
bleeding
DISEASE
. Satting 100% on Ra. Got levoflox in ED..On the floor He denied other complaints.Past Medical History:
Non-small cell lung cancer
DISEASE
: large
cell carcinoma
DISEASE
(locallyadvanced clinical stage T4 N0-1 M0) in [**2177**].s/p neoadjuvant chemotherapy (Carboplatin/Taxotere) [**9-13**]s/p
chemoradiation
DISEASE
(Radiation Admission Date: [**2180-9-24**] Discharge Date: [**2180-9-28**]Service: UROLOGY
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 5724**]Chief Complaint:
Hematuria
DISEASE
Major Surgical or Invasive Procedure:Cystoscopy clot evacuation prostatic urethra fulguration Dr.[**Last Name (STitle) 986**] [**2180-9-26**].History of Present Illness:86 y/o male with hx of BPH and indwelling foley catheterpresenting to the ED with 3 days of
hematuria
DISEASE
. He came to theED on [**9-23**] with
hematuria
DISEASE
and was discharged to his nursing homewith instructions to irrigate the catheter as needed and followup with Dr. [**Last Name (STitle) 986**] as an outpatient. Last night the nursinghome was unable to irrigate his catheter. They removed hiscatheter and were unable to replace the catheter. He failed tovoid and had suprapubic discomfort. He was taken to the ED andan 18F 3 way foley was placed with gross
hematuria
DISEASE
drainage.CBI was started but the catheter stopped draining. He finished5 doses of levaquin on [**2180-9-23**]. He was recently admitted to [**Hospital1 2025**]s/p fall/failure to thrive. Of note he had a voiding trial on[**2180-9-12**] which he failed. History is obtained from the patient'swife and through [**Name (NI) **] translator/ ED resident.Past Medical History:PMH:BPHIndwelling foley catheter
HTN
DISEASE
CAD s/p MI [**2170**]Hx
orthostatic hypotension
DISEASE
Hx of fallsVit D deficiency
PSH
DISEASE
:NoneSocial History:Normally lives with his wife at home. Admitted to [**Hospital3 **]on [**2180-9-6**] after discharge from [**Hospital1 2025**]. No tobacco/EtOH.Physical Exam:VS: Afebrile HR 83 BP 146/81 RR 20 97%RANAD A&Ox3No respiratory distressAbd: Soft nondistended nontenderGU: 18F 3 way foley in place (placed by ED) no CBI running withdark red drainage in bag Admission Date: [**2106-10-31**] Discharge Date: [**2106-11-15**]Date of Birth: [**2028-12-1**] Sex: FService: MEDICINE
Allergies
DISEASE
:Sulfa (Sulfonamides) / Codeine / Ciprofloxacin / PenicillinsAttending:[**First Name3 (LF) 2297**]Chief Complaint:Back
Pain
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Ms. [**Known lastname **] is a 77 year-old female with
osteoporosis
DISEASE
and multiple
vertebral compression fractures
DISEASE
status post vertebroplasty andkyphoplasty last [**10-8**] by Dr. [**Last Name (STitle) 5730**] at [**Hospital1 2025**] (T10) also with
COPD
DISEASE
and
bronchiectasis
DISEASE
on home oxygen 2L/min for 1 month andchronic
hyponatremia
DISEASE
secondary to SIADH who presents from homewith increasing
back pain
DISEASE
.*She reports that she has baseline back discomfort from hermultiple previous interventions but has noted significantworsening in the past 2 days bilateral with midline sparingwrapping around to axilla bilaterally worse at the level of hermost recent surgery but also diffuse. She denies
paresthesia
DISEASE
ornew
extremity weakness
DISEASE
no difficulty urinating or defecating.She denies
fever
DISEASE
or
chills
DISEASE
. On a different note she reportschronic severe
shortness of breath
DISEASE
stable over the past monthfor which she uses 2L home oxygen. She denies
phlegm
DISEASE
productionno
chest pain
DISEASE
and endorses mild chronic LE
edema
DISEASE
which has beenattributed to her Norvasc. She sleeps with multiple pillows dueto her
kyphosis
DISEASE
and SOB no change recently.*In ED T 98.2 HR 76 BP 182/75 RR 24 Sat 100% on 2L/min. Tand L-spine X-rays did not reveal new
fractures
DISEASE
CXR withfindings consistent with
bronchiectasis
DISEASE
CT chest without PE butwith interval increase in
bronchiectatic
DISEASE
and peribronchialinflammatory changes. She was evaluated by neurosurgery deemedto be intact neurologically. She is being admitted for ongoing
pain
DISEASE
control.Past Medical History:#
chronic back pain compression fractures
DISEASE
#
COPD
DISEASE
with
bronchiectasis
DISEASE
dx [**2080**]. [**2103**] with MYCOBACTERIUMKANSASII and pseudomonas.#
hemorrhoids
DISEASE
#
hemorroidal prolapse
DISEASE
with
GIB
DISEASE
# SIADH# perirectal abscess s/p I/D in [**3-7**]# Pulmonary nodules#
Lower extremity edema
DISEASE
#
osteoporosis
DISEASE
#
mitral valve prolapse
DISEASE
# spinal stenosis# 1Admission Date: [**2133-5-12**] Discharge Date: [**2133-5-17**]Date of Birth: Sex: MService:HISTORY OF PRESENT ILLNESS: The patient is a 49-year-oldmale status post motor vehicle accident. The patient was arestrained driver involved in a moderate speed motor vehicleaccident with prolonged extrication.
Loss of consciousness
DISEASE
was reported. The patient is currently complaining of leftshoulder
pain
DISEASE
.PAST MEDICAL HISTORY: Depression.ALLERGIES: No known
drug allergies
DISEASE
.MEDICATIONS: Wellbutrin Lexapro and Adderall.PHYSICAL EXAMINATION: Temperature 98.8 heart rate 88 bloodpressure 130/83 respiratory rate 18 O2 saturation 100percent on two liters. The patient is in no acute distresswith a GCS of 15. Pupils equal round and reactive to light.The patient has a superficial left ear laceration and liplaceration. Heart is regular rate and rhythm. Normal S1 andS2. Chest is clear to auscultation bilaterally. Abdomen issoft nondistended slightly tender in the left lowerquadrant with no guarding. Rectal examination is hemenegative with normal tone. Back is nontender with no
deformities
DISEASE
. Extremities show no
deformities
DISEASE
two plusdorsalis pedis pulses are palpated.LABORATORY DATA: Hematocrit 43.4 normal chemistries normalcoagulation amylase 35 negative blood toxin screen urinetoxin screen positive for amphetamines lactate 2.3urinalysis with moderate blood. Films performed include achest x-ray which showed a widened mediastinum. Pelvis x-raywas negative. Head CT was negative. Neck CT was negative.Chest CT showed a
lingula contusion
DISEASE
and a single rib
fracture
DISEASE
. Abdomen and pelvic CT showed a small spleniclaceration. Left shoulder film was negative.HOSPITAL COURSE: The patient was admitted to the IntensiveCare Unit at this time for close observation secondary to his
splenic laceration
DISEASE
. Serial hematocrit studies were performedshowing a persistently stable hematocrit and ruling out
enlargement
DISEASE
in the
splenic laceration
DISEASE
. The patient was alsoat that time placed on bed rest to prevent enlargement of his
splenic laceration
DISEASE
. Due to the apparent stability of his
splenic laceration
DISEASE
the patient was transferred to the flooron hospital day two. On postoperative day three the patientwas restarted on oral nutrition which he tolerated well.Physical Therapy consultation was obtained to ensure that thepatient did not have any
residual deficits
DISEASE
. He passedphysical therapy with flying colors. Over the course of thepatient's stay however the patient became
thrombocytopenic
DISEASE
.The question arose if the patient had developed heparinsensitive antibody to platelets. A heparin panel was sentwhich was negative. The patient's platelet count didstabilize. Due to his otherwise relative stability thepatient was discharged on [**2133-5-17**] in stable condition tofollow-up in the
Trauma
DISEASE
Clinic in approximately two weeks. Hehas been told he can resume normal activity resume a normaldiet and resume home medications. He is being sent home withPercocet for
pain
DISEASE
. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**] [**MD Number(1) 5733**]Dictated By:[**Last Name (NamePattern1) 3956**]MEDQUIST36D: [**2133-7-13**] 12:09:49T: [**2133-7-13**] 13:22:07Job#: [**Job Number 5734**]Admission Date: [**2145-5-6**] Discharge Date: [**2145-5-15**]Service: Cardiothoracic SurgeryHISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old femalewith a history of
gastritis hypertension
DISEASE
and
hypercholesterolemia
DISEASE
who was admitted to the [**Hospital Unit Name 196**] Service on[**2145-5-6**] for the
complaint
DISEASE
of progressive
chest pain
DISEASE
.The patient described a two to three month history ofprogressive
shortness of breath and substernal chest pain
DISEASE
.The patient stated that the
chest pain
DISEASE
originally occurred atrest and reported that her episodes had become more severeover the ensuing time. The patient's episodes werecharacterized by
pain
DISEASE
radiating to both arms that wouldoccasionally wake her up at night and lasted approximately 30minutes in duration. The patient was reportedly evaluated byher primary care physician and was presumptively diagnosedwith gastritisAdmission Date: [**2153-6-20**] Discharge Date: [**2153-6-24**]Date of Birth: [**2115-6-30**] Sex: MService: MEDICINE
Allergies
DISEASE
:Rifampin / BactrimAttending:[**First Name3 (LF) 562**]Chief Complaint:
Fever
DISEASE
and SOBMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:37 year old male with advanced HIV resistent to many meds withrecent CD4 count of 140 and VL of 300000 up from 56000presents with 2 1/2 weeks of symptoms. Began as a sore throatand
hacking cough
DISEASE
with
fevers
DISEASE
over the past week. Fevers weresubjective. Cough worsened and caused tearing of the eyes andoccational
emesis
DISEASE
. Patient denies
hemoptysis
DISEASE
or change inbowel habits (baseline
diarrhea
DISEASE
). He was unable to bringanything up with his
cough
DISEASE
. On evening prior to presentationhe developed night sweats that soaked his sheets and measuredhis temp at 105. He was also feeling sob with walking up stairsover the past day. Denies orthopnea.In the ED presentation concerning for PCP. [**Name10 (NameIs) **] shows upper lobeinfiltrates bilat and patient has crackles and rales on exam.Vitals on presentation were notable for temp of 105 HR 130s
hypoxia
DISEASE
stable BP 130/80. He was given tylenol flagylcefepime azithro prednisone nebs bactrim IV 4L NS. ID wasconsulted re the bactrim as patient had a
hemolytic anemia
DISEASE
inthe past that was thought to be due to bactrim though this wasnever confirmed. Per PCP notes hct has been in the 40s mostrecently. Patient improved but was brought to ICU formonitoring of hct and pulm status.Past Medical History:HIV since late [**2127**]
camplobacter diarrhea
DISEASE
TB exposure and INHtherapy for 1 year
anal warts gonorrhea DM cellulitis
DISEASE
[**Female First Name (un) **] PPD neg had suicide attempt many years ago usingtylenol overdose.
Hemolytic anemia
DISEASE
[**2146**] (coombs Admission Date: [**2196-4-13**] Discharge Date: [**2196-4-19**]Date of Birth: [**2127-10-25**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1505**]Chief Complaint:asymptomaticMajor Surgical or Invasive Procedure:[**4-13**] CABG x 3History of Present Illness:68 yo male with abnormal stress test as part of routinephysical referred for cardiac catheterization which showed 2
vessel disease
DISEASE
and he was referred for surgery.Past Medical History:PMH/PSH:
Diabetes
DISEASE
diagnosed in [**2187**]
Hyperlipidemia
DISEASE
Renalcalculi costochondritis S/P
torsion
DISEASE
testicle with repairTonsillectomySocial History:quit tobacco 40 years agooccasional etohlives with wifeFamily History:NCPhysical Exam:HR 71 RR 17 BP 140/77NADLungs CTAB anteriorlyHeart RRR no M/R/GAbdomen soft/NT/NDExtrem warm no
edema
DISEASE
Pertinent Results:CHEST (PORTABLE AP) [**2196-4-16**] 7:29 AMCHEST (PORTABLE AP)Reason: interval change[**Hospital 93**] MEDICAL CONDITION:68 year old man with s/p POD 3 CABG now RAFREASON FOR THIS EXAMINATION:interval changePORTABLE CHEST ON [**2196-4-16**] AT 08:30INDICATION: Post-op CABG.COMPARISON: [**2196-4-15**].FINDINGS: The right CVL has been removed and there is no
pneumothorax
DISEASE
. A previously visualized left PTX is not seen onthe current study. Left
basilar atelectasis
DISEASE
and small effusionremain. No new
airspace disease
DISEASE
is seen.IMPRESSION: No PTX after right CVL removal and no new airspacedisease.[**2196-4-19**] 05:30AM BLOOD Hct-25.9*[**2196-4-18**] 05:20AM BLOOD WBC-12.6* RBC-3.14* Hgb-9.5* Hct-28.2*MCV-90 MCH-30.3 MCHC-33.7 RDW-14.5 Plt Ct-240[**2196-4-19**] 05:30AM BLOOD PT-21.7* INR(PT)-2.1*[**2196-4-18**] 05:20AM BLOOD PT-14.3* PTT-24.8 INR(PT)-1.2*[**2196-4-15**] 02:03AM BLOOD PT-12.8 PTT-25.4 INR(PT)-1.1[**2196-4-19**] 05:30AM BLOOD UreaN-30* Creat-1.0 K-4.2[**2196-4-18**] 05:20AM BLOOD Glucose-102 UreaN-37* Creat-1.2 Na-140K-4.4 Cl-103 HCO3-28 AnGap-13[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT[**Known lastname 5738**] [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 5739**] (Complete)Done [**2196-4-13**] at 2:33:55 PM FINALReferring Physician [**Name9 (PRE) **] Information[**Name9 (PRE) **] [**First Name3 (LF) **] R.Division of Cardiothoracic [**Doctor First Name **][**Hospital Unit Name 4081**][**Location (un) 86**] [**Numeric Identifier 718**] Status: Inpatient DOB: [**2127-10-25**]Age (years): 68 M Hgt (in): 67BP (mm Hg): 140/70 Wgt (lb): 176HR (bpm): 65 BSA (m2): 1.92 m2Indication: Intraoperative TEE for CABGICD-9 Codes: 786.05 786.51 440.0 413.9Test InformationDate/Time: [**2196-4-13**] at 14:33 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**] MDTest Type: TEE (Complete)3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**] MDDoppler: Full Doppler and color Doppler Test Location:Anesthesia West OR cardiacContrast: None Tech Quality: AdequateTape #: 2008AW1-: Machine: [**Pager number 5741**]Echocardiographic MeasurementsResults Measurements Normal RangeLeft Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cmLeft Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cmLeft Ventricle - Diastolic Dimension: 4.8 cm Admission Date: [**2188-1-14**] Discharge Date: [**2161-2-9**]Date of Birth: [**2141-8-5**] Sex: FService:ADMISSION DIAGNOSIS: Unstable
angina
DISEASE
.DISCHARGE DIAGNOSIS:1.
Coronary artery disease
DISEASE
.2. Status post coronary artery bypass graft times two.HISTORY OF THE PRESENT ILLNESS: The patient is a 46-year-oldwoman with a history of
chest pain
DISEASE
and positive stress testwho is referred for cardiac catheterization. Previously tothis she has had
chest pain
DISEASE
approximately once a month withincreasing frequency to approximately one to two times perweek. The
pain
DISEASE
is substernal chest pressure associated withleft arm
pain
DISEASE
. It usually occurs at rest and lasts betweenthree to 30 minutes. No associated
shortness of breath
DISEASE
.Positive for
dyspnea
DISEASE
on exertion.The patient had a positive ETT as well as a positive stressechocardiogram. She had cardiac catheterization performed on[**2188-1-11**] which revealed an ejection fraction of 60% rightdominant coronary artery system and 70% stenosis of the leftmain. The patient presents for revascularization.PAST MEDICAL HISTORY:1. Thirty pack year smoking history.2.
Hypercholesterolemia
DISEASE
.3.
Renal insufficiency
DISEASE
in the past.4. Bilateral reimplantation of the ureters at age ten.5. Cesarean section times two.6. Pilonidal cyst.7. Tonsillectomy.ALLERGIES: The patient is
allergic
DISEASE
to sulfa and shrimp. No
allergy
DISEASE
to dye.ADMISSION MEDICATIONS:1. Lipitor 20 mg q.d.2. Atenolol 50 mg q.d.3. Wellbutrin 300 mg q.d.4. Zoloft 100 mg q.d.5. Multivitamin q.d.6. Aspirin q.d.PHYSICAL EXAMINATION ON ADMISSION: General: The patient wasa middle-aged woman in no acute distress. HEENT:Normocephalic atraumatic. PERRL EOMI anicteric. Thethroat was clear. The neck was supple and midline withoutmasses or
lymphadenopathy
DISEASE
. Chest: Clear to auscultationbilaterally. Cardiovascular: Regular rate and rhythmwithout murmurs rubs or gallops. Abdomen: Softnontender nondistended without masses or
organomegaly
DISEASE
.Extremities: Warm noncyanotic nonedematous times four.Neurological: Grossly intact.LABORATORY DATA ON ADMISSION: CBC 11.8/14.2/40.7/193. INR1.0. Chemistries 143/4.3/105/33/10/0.6.HOSPITAL COURSE: The patient had coronary artery bypassgraft times two on [**2188-1-15**]. The patient tolerated theprocedure well and was transferred to the Intensive Care Uniton a propofol drip. The patient was extubated withoutincident on postoperative day number one. She was alsomaintained on a Neo drip for labile blood pressures.The patient was incredibly anxious and called out with anyprocedure as small as tape removal. She was much morecooperative after Ativan was begun.On postoperative day number one the patient was transfused 1unit of packed red blood cells for a hematocrit of 23. Posttransfusion the hematocrit was 27. Unable to wean Neo atthat time.On postoperative day number two the patient remained A pacedwith an underlying rhythm in the 70s to keep systolic bloodpressure greater than 90. Neo was weaned down and eventuallyto off. Physical Therapy began work with the patient.On postoperative day number three the patient wastransferred to the floor without incident. On the floor shecontinued to do well and diuresed off quite a bit of fluid.In addition she continued to work with Physical Therapy.The patient was cleared for discharge home on postoperativeday number five.On postoperative day number five the patient was dischargedto home tolerating a regular diet and adequate
pain
DISEASE
controlon p.o.
pain
DISEASE
medications and having had the chest tubes andwires discontinued.PHYSICAL EXAMINATION ON DISCHARGE: The patient is amiddle-aged woman who is intermittently quite anxious. Thevital signs were stable afebrile. The heart revealed aregular rate and rhythm without murmurs rubs or gallops.The chest was clear to auscultation bilaterally. There wasno sternal click and no sternal drainage. The patient doeshave 1Admission Date: [**2149-11-16**] Discharge Date: [**2149-11-20**]Date of Birth: [**2074-6-23**] Sex: FService: MEDICINE
Allergies
DISEASE
:IbuprofenAttending:[**First Name3 (LF) 1711**]Chief Complaint:Right coronary artery ST-elevation
myocardial infarction
DISEASE
Major Surgical or Invasive Procedure:Cardiac catheterizationHistory of Present Illness:Patient reports she was [**Location (un) 1131**] a book at 1500h at home todayand had sudden onset bilateral arm
pain
DISEASE
and
heaviness
DISEASE
from thebiceps to the lower arms and
chest pain
DISEASE
. Per telephone triageshe also had
wheezing
DISEASE
and was very anxious. She had never had
chest pain
DISEASE
like this before. She was sent to the ED and recieved325mg of ASA and Morphine 10mg IV prior to arrival. She receivedOxygen Plavix 600mg heparin bolus 4200u IV and integrillinbolus 12mg IV. EKG demonstrated STE in II III AvF as well asin Right sided leads V3-V6 concerning for
inferior infarct
DISEASE
and
RCA occlusion
DISEASE
. Paatient was taken to cath lab and underwent PTCAwith deployment of three BMS in the proximal RCA. She toleratedthe procedure well and was admitted to the CCU forpost-operative care..Cardiac review of systems is notable for absence of
chest pain
DISEASE
dyspnea
DISEASE
on exertionPast Medical History:ONCOLOGIC HISTORY: Initially presented with URI-symptoms in[**2144-9-17**]. CXR followed by CT scan showed
adenopathy
DISEASE
and
bronchial collapse
DISEASE
and a large hilar mass. Transbronchialneedle aspiration and biopsy showed
SCLC
DISEASE
. She was treated withcarboplatin and etoposide with radiation for a total of 4Admission Date: [**2145-12-12**] Discharge Date: [**2145-12-17**]Date of Birth: [**2075-9-16**] Sex: MService: [**Hospital1 139**] FirmHISTORY OF PRESENT ILLNESS: This is a 70-year-old man withhistory of recurrent
transitional cell carcinoma
DISEASE
of the
bladder anemia
DISEASE
and questionable
celiac sprue
DISEASE
who presentedwith
weakness
DISEASE
and
pallor
DISEASE
of [**1-31**] weeks duration followed bydecreased hematocrit and increased INR to the MICU. In[**2145-8-30**] the patient had a high retrograde urethralcatheter placed for BCG for recurrent transitional cell
carcinoma
DISEASE
in his right renal pelvis. He had a rightnephrostomy tube placed in [**9-30**]. He was treated every weekAdmission Date: [**2174-5-29**] Discharge Date: [**2174-6-9**]Date of Birth: [**2093-11-17**] Sex: FService: MEDICINE
Allergies
DISEASE
:AtorvastatinAttending:[**First Name3 (LF) 134**]Chief Complaint:
cough
DISEASE
SOBMajor Surgical or Invasive Procedure:RIJ placedHemodialysisHistory of Present Illness:Pt is an 80F with a history of severe AS CAD s/p nephrectomyfor
RCC
DISEASE
with
ESRD
DISEASE
recently started on
HD
DISEASE
and recent admission to[**Hospital1 18**] for
cough
DISEASE
[**Date range (1) 135**] p/w
cough
DISEASE
. Today she woke up fromsleep with
acute shortness of breath and cough
DISEASE
. NO
Chest pain
DISEASE
.Husband called 911. In the ER afebrile HR 120s SBP 110s. CXRwith Admission Date: [**2162-9-20**] Discharge Date: [**2162-9-27**]Date of Birth: [**2089-12-21**] Sex: FService: MEDICINE
Allergies
DISEASE
:Penicillins / NeomycinAttending:[**First Name3 (LF) 5755**]Chief Complaint:
fever
DISEASE
altered mental statusMajor Surgical or Invasive Procedure:noneHistory of Present Illness:72yo F
quadriplegic
DISEASE
with chronic indwelling foley presentedfrom [**Hospital1 1501**] to [**Hospital1 18**] ED via EMS on [**2162-9-20**] w/ decreased mentalstatus cloudy urine
fever
DISEASE
and
hypotension
DISEASE
..In the ER her SBP dropped quickly from 100 to 60s and code
sepsis
DISEASE
called. She was noted to have milky white urine comingfrom her indwelling foley catheter. Her foley catheter was thenchanged and she was started on IV abx - zosyn (despite report ofvague
allergy
DISEASE
) and linezolid. She initially required pressorsfor blood pressure control..Early in the [**Hospital Unit Name 153**] course pt was weaned off pressors. Blood cx'sreturned with pan sensitive e. coli. Urine culture at present isgrown two separate GNR's and decision was made to continue withdouble GNR coverage (Zosyn and levofloxacin) out of concern forpossible reistant pseudomonas. Other complication early incourse of [**Hospital Unit Name 153**] stay included
reanl failure
DISEASE
which is respondingwell to re-hydration. Pt also complained of a
headache
DISEASE
in the[**Hospital Unit Name 153**]. CT of head was without acute findings and
headache
DISEASE
responded fully to tylenol therefore no further work up waspursued by the [**Hospital Unit Name 153**] team..On arrival to floor pt denies any complaints.Past Medical History:# C4
quadriplegic
DISEASE
s/p fall [**5-21**]#
hiatal hernia
DISEASE
#
HTN
DISEASE
# h/o
decubitus ulcers
DISEASE
#
diverticulitis
DISEASE
# recurrent
UTI
DISEASE
from indwelling foley catheter -Admission Date: [**2151-6-7**] Discharge Date: [**2151-6-14**]Date of Birth: [**2073-10-17**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 922**]Chief Complaint:
Dyspnea
DISEASE
on Exertion with abnormal stress testMajor Surgical or Invasive Procedure:Coronary Artery Bypass Graft x 3(LIMA-Admission Date: [**2192-10-1**] Discharge Date: [**2192-10-3**]Date of Birth: [**2128-11-19**] Sex: MService: MEDICINE
Allergies
DISEASE
:CodeineAttending:[**First Name3 (LF) 898**]Chief Complaint:
melena chest pain
DISEASE
.Major Surgical or Invasive Procedure:EGD [**2192-10-2**].History of Present Illness:63M with history of
HTN
DISEASE
and
Hypercholesterolemia
DISEASE
presents with aone-week history of
melena
DISEASE
and
chest pain
DISEASE
..The patient underwent a Colonoscopy and EGD on [**2192-9-24**] after hewas found to be guaiac positive by his PCP in early [**Month (only) 359**].Colonoscopy showed
diverticulosis
DISEASE
of the sigmoid colon andproximal ascending colon. EGD revealed a
polyp
DISEASE
in the pylorusand a
polyp
DISEASE
in the second part of the duodenum both of whichwere biopsied. The procedure was uncomplicated and the patientwas discharged home. Two days later he developed black tarrystools approximately two episodes per day for five days. Overthis time he also developed [**2197-2-20**] substernal chest pressureassociated with climbing stairs and walking on an incline andrelieved with rest. The
pain
DISEASE
was
non-radiating
DISEASE
and associatedwith SOB and
dizziness
DISEASE
but not
N/V diaphoresis
DISEASE
or
palpitations
DISEASE
. He went to church on the day prior to admissionand was walking with a friend who is a nurse who told him thathe looked pale and that he should see a doctor. He had anadditional episode of
chest pain
DISEASE
and
melena
DISEASE
and decided topresent to the ED..In the ED the patient was hemodynamically stable with BP 129/60and HR 80. His cardiac enzymes were positive and he was given anASA and the plan was admission to [**Hospital Unit Name 196**]. His hct returned at 23.6(down from 44 in [**Month (only) 359**]) and he had guaiac positive stool. Hewas admitted to the MICU for observation.Past Medical History:1.
HTN
DISEASE
2.
Hypercholesterolemia
DISEASE
3. s/p Hernia Repair4. Stress test Admission Date: [**2194-6-5**] Discharge Date: [**2194-6-15**]Date of Birth: [**2128-11-19**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Codeine / Plavix / AspirinAttending:[**First Name3 (LF) 1283**]Chief Complaint:
exertional angina
DISEASE
and positive ETTMajor Surgical or Invasive Procedure:Cardiac Catheterization [**2194-6-5**]Coronary Artery Bypass Grafting x4 [**2194-6-9**] (LIMA to LAD SVG toDIAG SVG to OM SVG to PDA)History of Present Illness:65 y/o M with PMH of
HTN
DISEASE
CAD
hyperlipidemia
DISEASE
and chronic
thrombocytopenia
DISEASE
who initially presented to the CMI service [**6-5**]for elective cardiac cath. The patient had complained to his PCPof
exertional substernal chest pain
DISEASE
for the past two weeks. Hedescribes the
pain
DISEASE
as occurring when he does heavy lifting orotherwise exerts himself and resolving with rest..He underwent an outpatient stress-ECHO which showed apicalseptal dyskinesis post-exercise indicating
ischemia
DISEASE
. The LVEFwas reported as 70%. He presneted for elective admission andunderwent cardiac cath on [**6-5**] that showed the LMCA had a distal30% stenosis. The LAD had a calcified 50%
ostial stenosis
DISEASE
and80% serial mid stenoses. The
LCX
DISEASE
had no angiographicallyapparent disease. The OM1 had a 50% stenosis. The RCA had a 50%proximal and a 70% distal stenosis. With these findings it wasdecided to proceed with CABG. Given his severe
LAD disease
DISEASE
hewas started on heparin gtt to be continued until surgery couldbe performed. Given that the patient had received loading doseof plavix CABG will not occur until [**6-9**]. He is currently chest
pain
DISEASE
free.Past Medical History:1.
hypertension
DISEASE
2.
Hypercholesterolemia
DISEASE
3. s/p Hernia Repair4. Stress test Admission Date: [**2157-11-20**] Discharge Date: [**2157-11-25**]Service: MEDICINE
Allergies
DISEASE
:lisinoprilAttending:[**First Name3 (LF) 3256**]Chief Complaint:
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:[**2157-11-20**] endotracheal intubationHistory of Present Illness:Mr. [**Known lastname **] is an 88 yo M with h/o dCHF
COPD DM2 CKD
DISEASE
presentswith
acute shortness of breath
DISEASE
..Per family patient had become increasingly short of breath athome over the last few days. This morning he felt so short ofbreath that he insisted on coming to the ED. Also complainingof burning
chest pain
DISEASE
. Has been taking meds as prescribedreports Admission Date: [**2118-9-23**] Discharge Date: [**2118-9-30**]Date of Birth: [**2039-1-10**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 2901**]Chief Complaint:Low energy
cough
DISEASE
Major Surgical or Invasive Procedure:expiredHistory of Present Illness:79yoM with prior MI s/p PTCA
VT/VF
DISEASE
s/p ablation sCHF (last EF23% in [**2110**]) presenting with low energy
fatigue
DISEASE
abdominaldiscomfort.The patient reported progressively worsening
fatigue
DISEASE
and
lethargy
DISEASE
for the past 4 months associated with
nausea
DISEASE
. He alsoreports a progressive
dry cough
DISEASE
during that time period butdenies sputum production
fevers shortness of breath
DISEASE
or sickcontacts. [**Name (NI) **] does report sinus pressure but denies
headaches
DISEASE
rhinorrhea
DISEASE
or
sore
DISEASE
throat. Per ED report he had endorsedabdominal discomfort with
belching
DISEASE
but the patient currentlydenies this history. He also endorses increased significantwater intake recently with increased
pedal edema
DISEASE
. Hiscardiologist reports increased
facial edema
DISEASE
as well.Of note the patient has had difficulty with his gait for thepast 6 months which is documented in OMR. His primary carephysician was concerned for
Parkinsonian symptoms
DISEASE
given hisfacial expression gait imbalance and midl
tremor
DISEASE
. The patienthad declined neurological evaluation per OMR notes.On review of systems the patient denies
headache
DISEASE
visionchanges
confusion
DISEASE
or
somnolence sore
DISEASE
throat sputumproduction
rhinorrhea shortness
DISEASE
of
breath chest pain emesis
DISEASE
abdominal pain diarrhea dysuria polyuria
DISEASE
new or unusual
myalgias
DISEASE
or
arthralgias
DISEASE
or
rash
DISEASE
. He does report he was
constipated
DISEASE
last week and took an enema with improvement of hissymptoms. His last BM was reportedly yesterday and he deniesBRBPR or
melena
DISEASE
.In the ED initial VS were: 97 127 151/117 20 95% 3L.Sodium was discovered to be 115 and the patient was given NS700cc total. Head CT showed no evident
cerebral edema
DISEASE
. CXRshowed L lobe infiltrate with a round area in the center oflucency concerning for possible
cavitation
DISEASE
with radiologyrecommendation of further evaluation w/ CT scan given concernfor
abscess
DISEASE
. He received Levofloxacin 750mg Ceftriaxone 1gmAzithromycin 500mg (for Legionella coverage). He was noted tobe in new onset a fib with RVR and was given in the diltiazem10 mg IV x2 and 30 mg p.o. for rate control with good effect.He was admitted to the MICU for the degree of
hyponatremia
DISEASE
.Subsequent VS prior to transfer was: 134/116 and subsequently109/76 89 24 94% 3L.On arrival to the MICU the patient denied symptoms other than
fatigue
DISEASE
including
chest pain shortness
DISEASE
of
breath confusion
DISEASE
abdominal pain nausea
DISEASE
..Review of systems:(Admission Date: [**2102-7-27**] Discharge Date: [**2102-7-29**]Date of Birth: [**2063-8-23**] Sex: FService: MEDICINE
Allergies
DISEASE
:IodineAdmission Date: [**2103-12-21**] Discharge Date: [**2103-12-23**]Date of Birth: [**2063-8-23**] Sex: FService: MEDICINE
Allergies
DISEASE
:IodineAdmission Date: [**2195-3-23**] Discharge Date: [**2195-4-1**]Date of Birth: [**2112-12-21**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Sulfa (Sulfonamides)Attending:[**First Name3 (LF) 1283**]Chief Complaint:
Dyspnea
DISEASE
on exertionMajor Surgical or Invasive Procedure:[**2195-3-23**] Aortic Valve Replacement(25mm Mosaic Porcine Valve)Mitral Valve Replacement(29mm Mosaic Porcine Valve) Replacementof Ascending Aorta(26mm Gelweave) and
Atrial Myxoma
DISEASE
RemovalHistory of Present Illness:Mr. [**Known lastname 5784**] is an 81 year old male with known
atrial fibrillation
DISEASE
and
atrial myxoma
DISEASE
for approximately 9 years. Serialechocardiograms have revealed worsening
aortic insufficiency
DISEASE
and
mitral regurgitation
DISEASE
. He concomitantly has complained ofprogressive
dyspnea
DISEASE
on exertion [**1-3**] pillow orthopnea andworsening
cough
DISEASE
. Cardiac catheterization in [**2194-5-31**] showednormal coronary arteries and an LVEF of 50%. A transesophogealechocardiogram in [**2194-10-31**] confirmed 3Admission Date: [**2195-4-4**] Discharge Date: [**2195-4-16**]Date of Birth: [**2112-12-21**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Sulfa (Sulfonamides)Attending:[**First Name3 (LF) 1283**]Chief Complaint:Pleural effusion/Pericardial effusionMajor Surgical or Invasive Procedure:[**2195-4-7**] - Mediastinal exploration and mediastinal
hematoma
DISEASE
evacuation.History of Present Illness:This 82-year-old gentleman with known
atrial fibrillation
DISEASE
and an
atrial myxoma
DISEASE
who underwent serial echocardiograms that haverevealed worsening aortic
insufficiency
DISEASE
and
mitral regurgitation
DISEASE
. Based on these findingshe underwent an aortic valve replacement as well as mitral valvereplacement and
atrial myxoma
DISEASE
excision. This was performed on[**2195-3-23**]. He was discharged home and while he was in a hotelwhere he was staying several days after he was discharged hehad a
syncopal
DISEASE
episode. During the
syncopal
DISEASE
episode the familydialed 911 the patient was
hypotensive
DISEASE
w/respiratory distressand was intubated. A large left
pleural effusion
DISEASE
was drained for1400 cc serosanguinousfluid. After the patient was hemodynamically stabilized he wastransferred to [**Hospital1 18**]. he underwent an echocardiogram whichrevealed a large
mediastinal hematoma
DISEASE
with some signs of earlytamponade. Based on these findings it was decided to take thepatient back to the operating room .Past Medical History:Congestive Heart Failure(diastolic) Aortic Insufficiency
Mitral Regurgitation Atrial Myxoma Dilated
DISEASE
Ascending Aorta
Atrial Fibrillation Hypertension Hyperlipidemia
DISEASE
Benign
Prostatic Hypertrophy Sleep Apnea
DISEASE
- on CPAP ObesitySocial History:Retired lives with wife in [**Name (NI) 108**]. Quit cigars over 10 yearsago. Admits to social ETOH consumption.Family History:Denies premature coronary disease(before age 55)Physical Exam:Admission94 139/80 100% on VentWDWN man intubated and sedatedIrregular rate and rhythmObese
NT/ND
DISEASE
NABS Triple lume in groinEXT: 2Admission Date: [**2188-11-1**] Discharge Date: [**2188-11-8**]Service: Medicine [**Hospital1 139**]HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-oldfemale who has a past medical history significant for
coronary artery disease hypertension dementia
DISEASE
recurrent
pneumonia
DISEASE
and recent gastrectomy for
peptic ulcer disease
DISEASE
who presented to the emergency room with a
complaint
DISEASE
ofincreasing
shortness of breath
DISEASE
. The patient had been at homefor approximately 2 days following discharge from rehabfollowing gastrectomy when
shortness of breath
DISEASE
developed.Emergency medical services were called and the patient wasfound to have an oxygen saturation of 65% on room air and 85%on 100% non-re-breather.PAST MEDICAL HISTORY:1. Hypothyroid.2. Coronary artery disease.3.
Hypertension
DISEASE
.4. Peptic ulcer disease status post gastrectomy forperforated
ulcer
DISEASE
.5. Dementia.6. Esophageal motility disorder.7. Recurrent
pneumonia
DISEASE
.SOCIAL HISTORY: Living situation - the patient at baselineresides at home with 24 hour home health assistance. Thereis extensive family involvement. The patient's code statusis DNR DNI.FAMILY HISTORY: Noncontributory.ALLERGIES: Sulfa.MEDICATIONS:1. Aricept 10 mg.2. Lasix 40 mg.3. Prevacid 30 mg.4. Lopressor 25 mg b.i.d.5. Multi-vitamin.6. Effexor 70 mg.7. Prednisone 25 mg.8. Zofran p.r.n.9. Synthroid 15 mg.
EXAM
DISEASE
: On presentation to the emergency department thepatient was found to have vital signs as follows:Temperature 98.7 heart rate 82 blood pressure 160/62respiratory rate 25 oxygen saturation 87% on room air. Ingeneral the patient is a well nourished but thin female in
respiratory distress
DISEASE
. There was no
jugular venous distention
DISEASE
on examination of the neck. Lung exam revealed decreasedbreath sounds bilaterally. Cardiovascular exam wasunremarkable. The PEG site was clean dry and intact. Thepatient was alert and oriented only to person.LABORATORY STUDIES: Admission CBC was unremarkable.Admission SMA-7 was significant for an elevated BUN tocreatinine ratio consistent with
dehydration
DISEASE
. Urinalysis wasunremarkable. Cardiac enzymes were significant for anisolated elevated troponin. Coagulation studies wereunremarkable. Arterial blood gas on 100% oxygen wassignificant for a decreased pO2 of 70 and an elevated pCO2 of59 with a normal pH.RADIOLOGY: Chest x-ray on admission revealed mild congestive
heart failure
DISEASE
markedly improved since the prior study of[**2188-8-17**]. There was also bilateral lower lobeopacification concerning for
pneumonia
DISEASE
. CT angiogramrevealed consolidations at both lung bases consistent with
bibasilar pneumonia
DISEASE
as well as subtle patchy opacificationsin the upper lobes with air fluid levels in the esophagussuggesting possible aspiration. There was no evidence of
pulmonary embolism
DISEASE
.CARDIAC STUDIES: EKG on admission revealed sinus rhythm withmild left axis deviation. There was also felt to be possibleleft anterior fascicular block. The admitting MICU teamnoted possible ST elevations in V3 through V6.Echocardiogram revealed mild symmetric left ventricular
hypertrophy
DISEASE
with normal left ventricular cavity size.Overall left ventricular systolic function was normal. Therewas normal right ventricular systolic function. There wasalso moderate
aortic regurgitation
DISEASE
. No
pericardial effusion
DISEASE
.HOSPITAL COURSE:1.
Respiratory distress
DISEASE
: On admission the patient was feltto have bilateral
pneumonia
DISEASE
most likely secondary toaspiration. The patient was started on IV Levaquin Flagyland Vancomycin to cover for likely aspiration in a setting ofrecent nursing home admission. The patient was kept onsupplemental oxygen to keep oxygen saturations above 92% andwas kept NPO on aspirations precautions. On day of admissionantibiotics were changed to IV
ceftazidine Flagyl
DISEASE
andVancomycin. Vancomycin was dosed at 1 gram q24 hours in thesetting of patient's decreased renal function age and bodysize. On day two of admission the patient was also felt tobe fluid over loaded and gentle diuresis was resumed. On daytwo of admission the patient was felt to be stable fortransfer to the floor. On the floor the patient wasinitially continued on IV antibiotics. On day five ofadmission the patient had a follow up chest x-ray whichrevealed marked improvement in
bibasilar pneumonia
DISEASE
. Thepatient also had improvement in oxygen saturation and wasable to tolerate room air. As a result the patient wastransitioned to p.o. antibiotics and was given Augmentin andFlagyl through the PEG tube. The patient was discharged homeon hospital day 9 with instructions to complete a 14 daycourse of p.o. antibiotics for presumed aspiration
pneumonia
DISEASE
.2. Cardiovascular: Elevated troponin as well as possible STelevations on admission were felt to reflect a demand
ischemia
DISEASE
. Cardiac enzymes and EKG changes stabilized. Thepatient was continued on aspirin Lopressor throughout theadmission. On day three of admission the patient had anepisode of
sinus tachycardia
DISEASE
likely secondary to
dehydration
DISEASE
versus multi-focal
atrial tachycardia
DISEASE
secondary to pulmonarydisease. This resolved following hydration. The patient'scardiovascular function remained stable for the rest of theadmission.3. Dementia: The patient was continued on Ariceptthroughout the admission.4. Gastrointestinal: Following rehydration the patient wasfound to have a mildly decreased hematocrit. As a resultthe patient was received an elevation by gastroenterology tolook for
gastrointestinal bleeding
DISEASE
as an etiology ofdecreased hematocrit. Given the patient's history of peptic
ulcer disease
DISEASE
gastroenterology service recommended H. pyloriserology which was negative. Iron studies were sent whichrevealed a decreased total iron binding capacity as well asdecreased iron suggestive of a combination of both
blood loss
DISEASE
and
chronic disease
DISEASE
as etiologies of
anemia
DISEASE
.Gastroenterology service felt however that EGD andcolonoscopy were not an option in setting of patient's recent
ischemic cardiac disease
DISEASE
. Furthermore the patient refusedgastroenterology work up. Gastroenterology service alsoasked to evaluate patient for possible contribution of refluxof jejunostomy tube feedings to development of aspiration
pneumonia
DISEASE
. Gastroenterology service felt that reflux ofJ-tube feedings was unlikely however felt that patient'slong history of
esophageal dysmotility
DISEASE
could be contributingto aspiration. They recommended swallowing study. Thepatient received an oropharyngeal video fluoroscopicswallowing evaluation on day five of admission. Thisrevealed mild oral with moderate to severe pharyngoesophageal
dysphagia
DISEASE
with significant
impaired upper esophageal
sphincter
DISEASE
opening leading to severe residue of solids in thepharynx. However there was no aspiration. Neverthelessswallowing service recommended the patient in future haveonly thin liquids pureed solids or very finely/minced meatin p.o. diet. They also recommended that the patient sitbolt upright at meals and for 45 minutes after meals. Theyrecommended the patient remain at 45 degrees in bed at alltimes and should never lay flat in bed and recommended thatif patient must remain flat in bed that tube feedings bediscontinued for 30 minutes prior to patient laying flat inbed.5. Endocrine: The patient was continued on Levothyroxinefor
hypothyroidism
DISEASE
.6. GU: The patient was placed on Foley catheter onadmission to the hospital. On day seven of admission thepatient was ready for discharge from a medical standpointbut did not void in time status post discontinuation of theFoley catheter. As a result the patient remained in-housefor an additional day to ensure the patient could voidspontaneously following discontinuation of Foley catheter.POST DISCHARGE MEDICATIONS: Metronidazole 500 mg q8 hours x7days Augmentin 500/125 mg p.o. b.i.d. x7 days furosemide 40mg p.o. q.d. aspirin 325 mg p.o. q.d. metoprolol 25 mg p.o.b.i.d. Venlafaxine HCL 75 mg capsule p.o. q.d.Levothyroxine 150 mcg p.o. q.d. donepezile hydrochloride 10mg p.o. q.h.s. Lansoprazole 30 mg q.d. iron sulfate 325 mgp.o. q.d. multi-vitamin.DISPOSITION: To home with visiting nurse as well as 24 hourhome health assistance.DISCHARGE STATUS: On day of discharge the patient wasambulating voiding spontaneously and had oxygen saturationof 97% on two liters. The patient was demented in a mannerconsistent with baseline.DISCHARGE DIAGNOSES:1. Aspiration
pneumonia
DISEASE
.2. Coronary
artery disease
DISEASE
.3.
Hypertension
DISEASE
.4. Peptic ulcer disease status post gastrectomy.5. Hypothyroidism.6. Dementia.7. Esophageal dysmotility.8. Dehydration.CODE STATUS: DNR and DNI.RECOMMENDED FOLLOW UP: Follow up with Dr. [**First Name4 (NamePattern1) 140**] [**Last Name (NamePattern1) 141**][**Telephone/Fax (1) 142**] if new problems arise. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**] M.D. [**MD Number(1) 144**]Dictated By:[**Last Name (NamePattern1) 145**]MEDQUIST36D: [**2188-12-13**] 16:12T: [**2188-12-15**] 06:37JOB#: [**Job Number 146**]Admission Date: [**2195-5-27**] Discharge Date: [**2195-6-4**]Date of Birth: [**2112-12-21**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Sulfa (Sulfonamides)Attending:[**First Name3 (LF) 5790**]Chief Complaint:Recurrent left lower lobe effusionMajor Surgical or Invasive Procedure:Flexible bronchoscopy decortication and parietalpleurectomy diaphragmatic plication.History of Present Illness:Mr. [**Known lastname 5784**] is an 82 year-old male s/p
AVR/MVR
DISEASE
(pericardial)right
atrial myxoma
DISEASE
resection AsAo graft [**3-7**] chronic atrial
fibrillation
DISEASE
who has had a left-sided
pleural effusion
DISEASE
andmarked
dyspnea
DISEASE
since a cardiac operation. He appears to have afluid collection most recently which was not accessible byultrasound-guided thoracentesis.Past Medical History:Left pleural Effusion
Atrial Fibrillation
DISEASE
Diastolic heart failure
DISEASE
(EF 45%)
Hypertension
DISEASE
Obstructive sleep apnea
DISEASE
on CPAPGERD[**Month/Year (2) 5783**][**3-7**] Resection of
Right atrial myxoma AVR/MVR
DISEASE
(pericardialAdmission Date: [**2117-8-9**] Discharge Date: [**2117-8-30**]Date of Birth: [**2042-9-7**] Sex: FService: MEDICINE
Allergies
DISEASE
:AlbuterolAttending:[**First Name3 (LF) 3326**]Chief Complaint:
Nausea
DISEASE
and
vomiting
DISEASE
Major Surgical or Invasive Procedure:ParacentesisHistory of Present Illness:Ms. [**Known lastname 5796**] is a 74 yo G3P3 scheduled for TAH/BSO debulking on[**8-10**]presenting to the ED with
N/V
DISEASE
after initiating her bowel prepyesterday. She used approximately 1.5 of the 3 bottles of prepand since then has had continuous
N/V of brown coffee-grounds
DISEASE
emesis
DISEASE
. She also reports
diarrhea
DISEASE
per the bowel prep but deniesany blood in her stoolAdmission Date: [**2170-5-7**] Discharge Date: [**2170-5-10**]Date of Birth: [**2140-6-19**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1850**]Chief Complaint:Toxic ingestion in suicide attemptMajor Surgical or Invasive Procedure:Intubated and extubatedHistory of Present Illness:29 yo male with h/o
depression
DISEASE
and
ADHD
DISEASE
who presented to ED withingestion of Nyquil and ibuprofen in suicide attempt. Patientnotes history of
depression
DISEASE
secondary to recent
death
DISEASE
of sisterand not taking his Paxil for past 2 months. Pt was on MassHealth but did not complete forms and lost coverage 2 months agoso had no way to pay for Paxil. Per pt's mother on night ofadmission pt called her to tell her he took some pills. Hedrove to her house and she found him to be lethargic. In EDgiven
Narcan
DISEASE
with no result. Pt intubated for airway protectionwith dose of vercuronium for
agitation
DISEASE
. Pt given 1.2 grams ofN-acetylcysteine and activated charcoal x1. EKG showed ST at106 normal axis normal intervals TWI in III AVF. Pt had mild
transaminitis
DISEASE
. Toxicology was consulted and recommendedsupportive care including follow LFT's and re-checking EKG. Toxscreen was only pos for amphetamines.Past Medical History:
Depression
DISEASE
-no previous
psychiatric
DISEASE
admission (PCP-[**Last Name (NamePattern4) **]. [**Last Name (STitle) 2903**]prescribes paxil)
ADHD
DISEASE
Social History:Lives with roommate in [**Location (un) 745**]. Plays piano gives lessons.Sister died 2-3 months ago from
crack overdose
DISEASE
. No ETOH or druguse.Family History:Admission Date: [**2177-5-14**] Discharge Date: [**2177-5-17**]Date of Birth: [**2146-7-21**] Sex: FService: SURGERY
Allergies
DISEASE
:
Dilaudid
DISEASE
Attending:[**First Name3 (LF) 668**]Chief Complaint:
ventral hernia
DISEASE
Major Surgical or Invasive Procedure:
umbilical and ventral hernia
DISEASE
repairHistory of Present Illness:30yo female currently on
HD
DISEASE
had
PD
DISEASE
catheter removed in [**Month (only) 116**][**2176**] with ongoing
complaint
DISEASE
of
pain
DISEASE
from an
umbilical hernia
DISEASE
.Past Medical History:-
ESRD
DISEASE
since [**2174-8-29**] currently on HD via tunneled line-
Peritonitis
DISEASE
[**8-7**]- Type I DM complicated by
neuropathy
DISEASE
and
nephropathy
DISEASE
- Bilateral
cataract
DISEASE
surgeries- Ventral HerniaSocial History:- Lives with her mother Admission Date: [**2177-6-20**] Discharge Date: [**2177-6-26**]Date of Birth: [**2146-7-21**] Sex: FService: MEDICINE
Allergies
DISEASE
:Dilaudid / Iodine-Iodine ContainingAttending:[**First Name3 (LF) 5806**]Chief Complaint:Chief Complaint: HeadacheReason for ICU Admission: Monitoring after contrast
allergic
DISEASE
reactionMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:History of Present Illness:Ms. [**Known lastname **] is a 30 year old lady on
HD
DISEASE
(previously
PD
DISEASE
until[**4-/2177**]) for
ESRD
DISEASE
secondary to type 1 DM for the past 3 years.Per her mother with whom she lives she developed a
headache
DISEASE
hypoglycemia nausea
DISEASE
and
vomiting
DISEASE
and
abdominal pain
DISEASE
with
chills
DISEASE
over the past day. She was also more combative and somnolent athome. She did have
HD
DISEASE
on Thursday as scheduled and per anephrology census note has a history of
catheter infections
DISEASE
.She was brought in by ambulance to the [**Hospital1 18**] for furtherevaluation..In the ED initial vs were: 100.4 90 [**Telephone/Fax (2) 5809**]. Patientunderwent LP after receiving Vanc CTX and acyclovir and bloodcultures. CSF unrevealing. The patient also underwent Head CTand CXR. She was slated for CT Ab/Pelvis with IV contrast toevaluate her
abdominal pain
DISEASE
given her recent
hernia
DISEASE
repair(despite her mother's protestations) and during the contrastexposure developed rapid
facial swelling oropharyngeal rash
DISEASE
without
wheezing
DISEASE
or hives. She was given SolumedrolFamotidine Benadryl and 1L NS for
allergic reaction
DISEASE
andtransferred to the ICU for further monitoring. CT Ab with POcontrast was obtained prior to transfer. Renal was consulted. VSib transfer: 87 199/93 14 100% RA- no
headache
DISEASE
or
chest pain
DISEASE
..On the floor the patient is somonolent but arousable. She istacitly refusing to answer questions but does respond tocommands and express her displeasure at my attempt to interviewher. A brief meeting with her mother confirmed the story above..Review of systems: Unable to obtainPast Medical History:Past Medical History:-
ESRD
DISEASE
since [**2174-8-29**] HD through L IJ Tunnelled line-
Peritonitis
DISEASE
[**8-7**]- Type I DM complicated by
neuropathy
DISEASE
and
nephropathy
DISEASE
- Bilateral
cataract
DISEASE
surgeries- Ventral Hernia repaired [**4-/2177**]Social History:- Lives with her mother Admission Date: [**2177-7-1**] Discharge Date: [**2177-7-3**]Date of Birth: [**2146-7-21**] Sex: FService: MEDICINE
Allergies
DISEASE
:Dilaudid / Iodine-Iodine ContainingAttending:[**First Name3 (LF) 5810**]Chief Complaint:
tachypnea hypoxia
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:30 YO F w
ESRD
DISEASE
[**12-31**]
DM1
DISEASE
on
HD
DISEASE
M/W/F s/p recent admission forcontrast
allergy
DISEASE
who presented with SOB after missing her
HD
DISEASE
session yest. Went to
HD
DISEASE
today but was found to be
tachypneic
DISEASE
tothe 30s w
bibasilar rales
DISEASE
. EMS gave 15L NRB 97%. Upon arrivalthe patient was 88% on
RA
DISEASE
. Exam was notable for bibasilarcrackles. She was started on BiPap and given 80IV lasix andnitro paste Ca gluconate for peaked T-waves 20u regularinsulin. Renal was contact[**Name (NI) **] and plan to do HD when she arrivesto the MICU..Upon arrival to the MICU the patient reports improved SOB withthe Bipap mask. She was noted by nursing to have an episode of
rigors
DISEASE
without
fever
DISEASE
..Review of sytems:(Admission Date: [**2140-3-15**] Discharge Date: [**2140-3-18**]Date of Birth: [**2082-7-23**] Sex: MService: CCUCHIEF COMPLAINT:
Chest pain
DISEASE
.HISTORY OF PRESENT ILLNESS: This is a 57 year old male with
hypercholesterolemia
DISEASE
and known
coronary artery disease
DISEASE
statuspost coronary artery bypass graft in [**2130**] with quiescentdisease since then not requiring sublingual NitroglycerinAdmission Date: [**2167-8-27**] Discharge Date: [**2167-9-2**]Date of Birth: [**2092-2-10**] Sex: FService:HISTORY OF PRESENT ILLNESS: The patient is a 75 year-oldfemale who was initially admitted to the Coronary Care Unitand then transferred to the [**Hospital Unit Name 196**] Service. She has a historyof chronic
atrial fibrillation congestive heart failure
DISEASE
mitral regurgitation hypertension BOOP
DISEASE
and status postrecent left hip
fracture
DISEASE
repair. The patient presented withpersistent worsening of
shortness of breath
DISEASE
. In theEmergency Department the patient was noted to be in rapid
atrial fibrillation
DISEASE
and
congestive heart failure
DISEASE
. After aCTA to rule out PE was done the patient at that timedeveloped worsening
hypoxia
DISEASE
and was transiently on BiPAP andwent to the Coronary Care Unit. After she was appropriatelyrate controlled and diuresed the patient was transferred tothe floor for further management of her
atrial fibrillation
DISEASE
.PAST MEDICAL HISTORY:1. Congestive
heart failure
DISEASE
EF of 40 to 50%2. Moderate to severe
mitral regurgitation
DISEASE
.3.
Hypertension
DISEASE
.4. Chronic
atrial fibrillation
DISEASE
.5. BOOP treated with steroids complicated by steroid
psychosis
DISEASE
.6. Glaucoma.7.
OSA
DISEASE
.8. History of falls.9. History of
angiopathy
DISEASE
.10. Status post cerebrovascular accident times three.11. Left hip
fracture
DISEASE
.ALLERGIES: Prednisone causes
psychosis
DISEASE
. Tape andBacitracinMEDICATIONS AS AN OUTPATIENT:1. Lasix 20.2. Diltiazem 120 once a day.3. Lipitor 10 once a day.4. Coumadin 3 mg alternating with 1.5 mg every other day.5. Synthroid.6. Advair.7. Albuterol.8. Methazolamide.PHYSICAL EXAMINATION: The patient was afebrile 97.8. Bloodpressure 140/70. Heart rate 100. Sating 96% on 2 litersnasal cannula. In general the patient was calm and in noacute distress. Head and neck examination JVD noted 10 to 11cm. Heart irregular irregular rapid heart with a systolicmurmur radiating to the apex. Lungs crackles at basesbilaterally. Abdomen soft and nontender. Extremities show1Admission Date: [**2133-2-28**] Discharge Date: [**2133-3-6**]Date of Birth: [**2062-6-29**] Sex: FService: MEDICINE
Allergies
DISEASE
:PhenerganAttending:[**First Name3 (LF) 2485**]Chief Complaint:transferred to [**Hospital1 18**] for bronchoscopyMajor Surgical or Invasive Procedure:bronchoscopyHistory of Present Illness:Mrs. [**Known lastname **] is a 70 year old woman with a history of severe
COPD
DISEASE
NSCLC
DISEASE
s/p LUL lobectomy [**2126**] s/p XRT vent-dependence has s/ptracheostomy since [**2130**] status post Y-stent placementsecondary to severe
chronic obstructive pulmonary disease
DISEASE
and
tracheobronchomalacia
DISEASE
in [**5-6**]. Y stent finally removed on [**7-6**]due to recurrent migration of Y stent.Patient has been at rehab where a tracheostomy was noticed to bemalfunctioning for the last days. Per nurse notes on [**2-27**]patient had a Admission Date: [**2133-3-24**] Discharge Date: [**2133-3-31**]Date of Birth: [**2062-6-29**] Sex: FService: MEDICINE
Allergies
DISEASE
:PhenerganAttending:[**First Name3 (LF) 338**]Chief Complaint:
Hemoptysis
DISEASE
Major Surgical or Invasive Procedure:BronchoscopyHistory of Present Illness:Pt is a 70yo woman with a history of severe
COPD NSCLC
DISEASE
s/p LULlobectomy [**2126**] s/p XRT vent-dependence with tracheostomy since[**2130**] status post Y-stent placement and removal in [**5-6**] h/otracheal ulceration recent admission with clogged trach andblood in trach tube however bronchoscopy with patent airwaysand pt discharged on course of Zosyn for possible Pseudomonas
pneumonia
DISEASE
(possibly sputum cx colonizer) who presented fromrehab today where she was found diaphoretic trach suctionedresulting in removal of mucous plug followed by persistent bloodin trach tube.In ED no blood was noted in/around trach. Pt was
febrile
DISEASE
at101F HR 90s BP 120/50. She was mildly sob and responded tocombivent. She was given Vancomycin and Azithromycin. labspertinent for
leukocytosis
DISEASE
and Lactate 1.0..ROS is negative for
fever chills cough
DISEASE
night
sweats
DISEASE
abdominal pain chest pain hematemesis
DISEASE
or
weight loss
DISEASE
.Past Medical History:1.
CHF
DISEASE
s/p
respiratory failure
DISEASE
s/p trach. ECHO [**5-6**] with EF Admission Date: [**2196-8-20**] Discharge Date: [**2196-8-23**]Date of Birth: [**2121-4-19**] Sex: MService: OMED
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 99**]Chief Complaint:
Hypotension
DISEASE
Major Surgical or Invasive Procedure:Central line placement at Right internal jugularHistory of Present Illness:75 yo male with advanced gastric ca recently started onchemotherapy presenting and hypotensiona nd episode ofunresponsivenes after
diarrhea
DISEASE
and narcotics Admission Date: [**2126-7-29**] Discharge Date: [**2126-8-2**]Service: MED
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 242**]Chief Complaint:
CHF dyspnea
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:88 yo with MMP (see below) who refuses all invasive medicaltherapy. Admitted with
dyspnea
DISEASE
increase [**Location (un) **] 5# wt gain.Patient had CP 2 days prior to admission as well. Eating suasageat home.In ED noted to be
tachypneic
DISEASE
with RR in 30s. Appeared in
CHF
DISEASE
and given 60-60-120 of IV lasix with only 280 UOP. Started onBiPAP with significant improvement in symptoms. Admission Date: [**2198-5-31**] Discharge Date: [**2198-6-6**]Date of Birth: [**2125-10-3**] Sex: MService: NEUROLOGY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 5831**]Chief Complaint:
Seizures
DISEASE
Major Surgical or Invasive Procedure:Intubation and ventilation at [**Hospital **] HospitalLumbar punctureHistory of Present Illness:cc:
Seizures
DISEASE
versus
syncope
DISEASE
transferred from [**Hospital1 **] at around3 am [**Hospital1 112**] was at maximal capacity therefore could not accept thetransfer.72 yo man with an extensive past medical history and of note:End Stage Renal Disease(started on hemodialysis one month ago)dialysis days Tue/[**Doctor First Name **]/SatNormal pressure
hydrocephalus
DISEASE
&
Parkinsonism
DISEASE
(s/p VP [**Hospital1 5832**]Hakim programmable shunt placed at the [**Hospital1 756**] in Han [**2198**] on[**5-25**] setting changed from 9--Admission Date: [**2168-12-29**] Discharge Date:Date of Birth: [**2129-12-2**] Sex: MService: ICUTHIS IS A DICTATION FROM THE HOSPITAL COURSE FROM [**2168-12-29**] THROUGH [**2169-1-14**].HISTORY OF PRESENT ILLNESS: Patient is a 39-year-old malewith a history of HIV not on HAART no history of
opportunistic infection
DISEASE
who presented with weeks ofworsening
dyspnea
DISEASE
. The patient refused to see his primarydoctor but the patient's ex-noted that he was becomingincreasingly dyspneic over the month prior to admission. Hismother who had not seen the patient for about a month notedthat he was increasingly short of breath on the phone. Onthe day of admission the patient complained of
dizziness
DISEASE
dyspnea
DISEASE
with minimal exertion. The patient's ex-roommatecalled EMS who brought the patient to the Emergency Room.Of note the patient was seen at [**Hospital6 1708**]Emergency Room several weeks prior to this presentation with
shortness of breath and malaise
DISEASE
. He was sent home withoutany therapy.In the Emergency Department the patient became increasinglyhypoxic on 100% nonrebreather with peripheral oxygensaturation to be 86%. The patient was intubated and placedon a
sepsis
DISEASE
protocol. He was aggressively volumeresuscitated and an arterial line was placed afterintubation. The patient became
hypotensive
DISEASE
with systolicblood pressure in the 70s and was started on a Levopheddrip. The patient was started on broad spectrum antibioticsand was transferred to the [**Hospital Ward Name 332**] Intensive Care Unit.PAST MEDICAL HISTORY:1. HIV. Unknown CD4 and viral load on admission. Thepatient was diagnosed about one and a half years ago. He hasnever been on HAART therapy secondary to concern about sideeffects. He denies any history of
opportunistic infection
DISEASE
.2. Congenially absent pyoid.3. Depression.ALLERGIES: Soap causes a
rash
DISEASE
.MEDICATIONS ON ADMISSION: Levoxyl 150 mcg po q.d.FAMILY HISTORY: Unable to be obtained.SOCIAL HISTORY: Patient lives alone used to have aroommate. Patient admits to a 25 pack year tobacco historyand quit two weeks prior to admission secondary to
shortness
DISEASE
of breath. Patient admits to a history of alcohol use andquit two weeks ago as well. The patient is sexually activeonly with men.PHYSICAL
EXAM
DISEASE
ON ADMISSION: Vital signs: Temperature 102.2.Blood pressure 80/40. Heart rate 132. Respiratory rate 30s.Oxygen saturation 64% on room air. In general patient is athin anxious appearing male in
respiratory distress
DISEASE
. Headand neck exam: Bloody mucosa poor dentition foul smelling.
Extraocular movements
DISEASE
intact. Lungs: Decreased breathsounds at right base. No crackles. Abdomen soft nontendernondistended. Good bowel sounds. Extremities: Nailsunkempt. No
edema
DISEASE
. Rectum: Multiple superficial abrasions.Decreased tone as per Emergency Room. Guaiac negative.LABORATORY
EXAM
DISEASE
ON ADMISSION: White blood cell count 10.9hematocrit 33.9 platelet count 396000. Sodium 133potassium 4.2 chloride 107 bicarbonate 19 BUN 22creatinine 0.6 glucose 149. Differential on CBC with 74%neutrophils 8.5% lymphocytes 16% monocytes 1% eosinophilsalbumin 1.8 calcium 6.9 phosphorus 3.7 magnesium 1.8 CK76 troponin less than 0.01 LDH 635 ALT 28 AST 66alkaline phosphatase 69 total bilirubin 0.9 lipase 149.Urinalysis: Specific gravity of 1.023 negative nitratenegative leukocyte esterase negative protein negativeblood lactate 1.7. Admission Date: [**2168-12-29**] Discharge Date: [**2169-1-17**]Date of Birth: [**2129-12-2**] Sex: MService: MEDICAL INTENSIVE CARE UNIT/ACOVE MEDICINEFor detailed hospital course during the patient'shospitalization in the Medical Intensive Care Unit pleaserefer to their discharge summary.CHIEF COMPLAINT: Hypoxic
respiratory failure
DISEASE
and
shortness
DISEASE
of breath.HISTORY OF PRESENT ILLNESS: The patient is a 39 year-oldmale with a history of HIV diagnosed one year ago with CD4count currently 25 not on treatment secondary to fearregarding side effects of medications. The patient also hasa history of
hepatitis C.
DISEASE
He was admitted with
weakness
DISEASE
progressive worsening
dyspnea hypoxia
DISEASE
and
hypotension
DISEASE
and
fever
DISEASE
. The patient was brought to the Emergency Room by EMS.In the Emergency Room his temperature was 102.2 pulse 130oxygenation 64% on room air and 86% on a nonrebreather.Blood pressure was 67/36 and lactate was 4.0. The patientreceived 7 liters of intravenous fluids of normal salineintubated sedated right IJ and A line were placed. Thepatient was started on Ceftriaxone Flagyl VancomycinLevophed GTT CVP increased to 12 with MBO2 75%. Chestx-ray with diffuse bilateral infiltrates concerning for PCP
sepsis
DISEASE
protocol initiated. The patient was intubated for atotal of two times for
hypoxic respiratory failure
DISEASE
. Hisbronch was positive times two for PCP and the patient wasstarted on Bactrim steroids. The patient also developedperirectal HSV type 2 lesions and started on Acyclovir. Thepatient had one out of four bottles of coag negative staphspecies felt to be contaminate and this was Admission Date: [**2168-12-29**] Discharge Date: [**2169-1-17**]Date of Birth: [**2129-12-2**] Sex: MService: A-COVEThe patient was initially admitted to the Medical IntensiveCare Unit and secondarily transferred to the A-Cove MedicineService under the care of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. For detailedhospital course during patient's hospitalization in theIntensive Care Unit please refer to their discharge summary.CHIEF COMPLAINT: Hypoxic
respiratory failure
DISEASE
and
shortness
DISEASE
of breath.HISTORY OF PRESENT ILLNESS: This is a 39-year-old male witha history of HIV diagnosed one year ago with CD-4 countcurrently 25 not on treatment secondary to fear regardingside effects of medication. Patient also has a history of
hepatitis B.
DISEASE
He was admitted with
weakness
DISEASE
progressiveworsening
dyspnea hypoxia
DISEASE
and
hypotension
DISEASE
and
fever
DISEASE
. Thepatient was brought to the Emergency Room by EMS and in theEmergency Room his temperature was 102.2 pulse 130.Oxygenation was 64% on room air and 86% on a non-rebreather.Blood pressure was 67/36 and lactate was 4.0. The patientreceived seven liters of intravenous fluid normal salinewas intubated sedated. Right internal jugular A-line wasplaced. The patient was started on ceftriaxone Flagylvancomycin Levophed GTT CVP increased to 12 with MBO2 75%.Chest x-ray with diffuse bilateral infiltrates concerning forPCP. [**Name10 (NameIs) **] protocol initiated. Patient intubated for atotal of two times for
hypoxic respiratory failure
DISEASE
. Hisbronch Admission Date: [**2102-7-12**] Discharge Date: [**2102-7-19**]Date of Birth: [**2024-1-14**] Sex: MService: ORTHOPAEDICS
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 64**]Chief Complaint:left hip
pain
DISEASE
Major Surgical or Invasive Procedure:left total hip replacement - revisionHistory of Present Illness:Mr. [**Known lastname 5849**] was working in hiscellar on [**2101-10-1**] when he tripped and fell on a stepand sustained a left subcapital hip
fracture
DISEASE
. As you know thiswas treated with an uncemented Osteonics Omnifithemiarthroplastyon [**2101-10-2**]. This was performed through ananterolateral approach. His postoperative course wasuneventful. Over the ensuing months he did receive treatment from anorthopedic surgeon in [**State 108**] whereby he was givenviscosupplementation injections of the left knee. He did nothave any improvement of his knee
pain
DISEASE
at that time.Subsequently in [**2102-3-13**] he was admitted with
pneumonia
DISEASE
. Atthat time his hip was painful and an x-ray revealed
subluxation
DISEASE
of the hemiarthroplasty. Aspiration was positive for
infection
DISEASE
.The aspiration white cell count on [**2102-4-11**] was 35500with97% polys. The patient was then taken to the operating room byDr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who performed a resection of thehemiarthroplasty irrigation and debridement and spacer withantibiotic cement. Tissue culture on [**2102-4-12**] revealedcoagulase negative
Staphylococcus
DISEASE
as well as propionibacteriumacnes. The patient was then subsequently treated withintravenous antibiotics and the spectrum was widened to includevancomycin ceftriaxone and azithromycin. He was discharged onan antibiotic regimen of vancomycin and ceftriaxone anddemonstrated improvement in his
fevers
DISEASE
and
pain
DISEASE
. He completedfive weeks of intravenous vancomycin. He developed
Clostridium
DISEASE
difficile infection
DISEASE
on [**2102-5-16**] which was treated withFlagyl. For this reason IV antibiotics were discontinued at five weeksrather than six weeks. Mr. [**Known lastname 5849**] now presents for assessmentfor reimplantation of the hip.Past Medical History:CAD s/p DES to RCA in [**11-20**]
Prostate cancer
DISEASE
s/p radical prostectomy [**2093**]
Hypertension
DISEASE
Hypothyroidism
DISEASE
dx early [**2082**]
Glaucoma
DISEASE
s/p bilateral ankle surgerycarpal tunnel s/p surgical release [**2100**]s/p L
hernia
DISEASE
repair [**2086**]Social History:Pt lives with wife in [**Name (NI) 1468**] recently from nursing home. Hedenies current tobacco use or illicit drug use. Admits tooccasional glass of wine. Used to own a sub shot.Family History:ncPhysical Exam:well-appearing well nourished 78 year old malealert and orientedno acute distressLLE: -dressing-c/d/i -incision-c/d/i Admission Date: [**2200-12-28**] Discharge Date: [**2200-12-31**]Date of Birth: [**2129-6-25**] Sex: MService: CCUHISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 5850**] is a 71-year-oldmale with an extensive cardiac history. His last cardiaccatheterization was [**7-25**] during which he had a stent to hisD1 and presented with
unstable angina
DISEASE
. Patient describesstable
angina
DISEASE
as
substernal chest pain
DISEASE
with walking Admission Date: [**2121-3-18**] Discharge Date: [**2121-3-26**]Date of Birth: [**2086-12-16**] Sex: FService: MEDICINE
Allergies
DISEASE
:Penicillins / Codeine / Nsaids / LevaquinAttending:[**First Name3 (LF) 425**]Chief Complaint:PalpitationsMajor Surgical or Invasive Procedure:Pulmonary vein isolation / ablationHistory of Present Illness:Ms. [**Known lastname **] is a 34 yo female with
hypertrophic cardiomyopathy
DISEASE
obesity anxiety
DISEASE
multifocal
atrial tachycardia
DISEASE
atrial
fibrillation left atrial tachycardia
DISEASE
and
AVNRT
DISEASE
. She wasadmitted after pulmonary vein isolation complicated by atrial
tachycardia
DISEASE
requiring cardioversion and SOB from pulm
edema
DISEASE
requiring post-procedure re-intubation.The patient was admitted for elective pulmonary vein isolation.Both groin veins were accessed for the procedure. At the end ofthe procedure she developed
atrial tachycardia
DISEASE
with 2:1 blockat a rate of approximately 100. This atrial tach was not ablatedthough she was cardioverted back to NSR. She was successfullyextubated after cardioversion. She had received an estimated4.5L of fluid during the procedure. She developed shortness ofbreath after extubation. Exam and CXR were concerning for
pulmonary edema
DISEASE
. She responded well to 40mg IV lasix x2 with anestimated 3L urine output. Nonetheless the patient's shortnessof breath worsened saturating 92% on
NRB
DISEASE
and speaking in shortsentences. She required re-intubation and received propofol andvecuronium during intubation.She has been hospitalized several times over the past 1-2 monthswith symptoms of
palpitations
DISEASE
and
dyspnea
DISEASE
associated with atrial
arrhythmias
DISEASE
.Past Medical History:
Hypertrophic cardiomyopathy
DISEASE
on transplant listIntermittent
atrial fibrillation
DISEASE
s/p
cardiac arrest
DISEASE
at age of 16yos/p MVA
Chronic back pain
DISEASE
Asthma
COPD
DISEASE
Bipolar
DISEASE
Anxiety
DISEASE
s/p appendectomymultiple cardiac cathss/p cardioversion.Cardiac Risk Factors: -
Diabetes - Dyslipidemia - Hypertension
DISEASE
.Cardiac History:The patient initially presented with
syncope
DISEASE
at age of l2. Atl3 the patient was seen at [**Hospital3 1810**] for history of
syncope chest pain
DISEASE
and progressive
exercise intolerance
DISEASE
. Shewas found to have
hypertrophic cardiomyopathy
DISEASE
. She wassubsequently cathed. Leftventricular end diastolic pressure was found to be 20. She wasthen started on chronic Verapamil therapy. At age l6 sheexperienced
cardiac arrest
DISEASE
secondary to complex
tachycardia
DISEASE
. Shewas successfully resuscitated. Repeat catheterization showedleft ventricular end diastolic pressure of 36-40 without outflow
tract obstruction
DISEASE
. EP showed inducible
atrial flutter
DISEASE
with arapid ventricular blood pressure. She was felt to have a rapidantegradeconduction and possible
pre-excitation
DISEASE
. She was started onNorpace. Since then the patient has been stable on Verapamiland Norpace with occasional palpitations
chest pain
DISEASE
and light
headedness
DISEASE
..Social History:Currently on disability. 40 pack-year smoker (2ppd x20 years)quit since recent
bronchitis
DISEASE
. No EtOH. Regular marijuana use.Family history remarkable for
hypertrophic cardiomyopathy
DISEASE
and
congenital aortic stenosis
DISEASE
s/p cardiac surgery during infancy.No family history of sudden
cardiac death
DISEASE
or
premature CAD
DISEASE
.Family History:There is no family history of
premature coronary artery disease
DISEASE
or
sudden death
DISEASE
. Mom has DM HTN. Her son has
aortic stenosis
DISEASE
and
hypertrophic cardiomyopathy
DISEASE
.Physical Exam:ADMISSION PHYSICAL
EXAM
DISEASE
:VS: 98.2-99.2 60-80 100-120/40-60 SIMV RR 10 Vt 650 FiO2 60 PEEP8 99%Gen: Obese. Intubated and sedated.CV: RRR. Normal S1 and S2. No M/R/G.Pulm: Coarse breath sounds bilaterally in part due to upper
airway congestion
DISEASE
.Abd: Soft nontender. No
organomegaly
DISEASE
or masses.Ext: No
edema
DISEASE
. Bilateral palpable 1Admission Date: [**2121-4-5**] Discharge Date: [**2121-5-9**]Date of Birth: [**2086-12-16**] Sex: FService: MEDICINE
Allergies
DISEASE
:Penicillins / Codeine / Nsaids / LevaquinAttending:[**First Name3 (LF) 1711**]Chief Complaint:transfer s/p pericardial windowMajor Surgical or Invasive Procedure:noneHistory of Present Illness:In brief this is a 34 yoF with
hypertrophic cardiomyopathy
DISEASE
multiple
atrial arrhythmias
DISEASE
including
atrial tachycardia
DISEASE
atrial
fibrillation left atrial tachycardia
DISEASE
and
AVNRT
DISEASE
s/p recentpulmonary vein isolation procedure [**2121-3-18**] c/b peristent atrial
tachycardia respiratory failure
DISEASE
and
pneumonia
DISEASE
who wasreadmitted to [**Hospital1 18**] on [**2121-4-5**] with
chest pain
DISEASE
and shortness ofbreath. She initially presented to an OSH w/ intermittent [**11-21**]
chest pain
DISEASE
radiating to the arms associated with SOB. CT chestwas negative for PE or dissection. She was found to have a
pericardial effusion
DISEASE
with
RV compression
DISEASE
as well as apericardial clot on TTE. She was sent to the OR for pericardialwindow on [**2121-4-5**] which showed Admission Date: [**2200-4-7**] Discharge Date: [**2200-5-30**]Date of Birth: [**2166-12-24**] Sex: MService: MEDICINE
Allergies
DISEASE
:Codeine / CeftriaxoneAttending:[**First Name3 (LF) 2641**]Chief Complaint:MS changes (tx'd from OSH)Major Surgical or Invasive Procedure:[**2200-4-11**]- R Hip washout secondary to infected hardward[**2200-4-17**]- R Hip Hardware removed[**2200-4-24**]- R Hip washed out and wound closed[**2200-5-8**]- Removal of
infected hematoma
DISEASE
in R hip[**2200-5-22**]- R hip WashoutHistory of Present Illness:33 y/o male with PMH significant for AVR
NIDDM
DISEASE
h/o
polysubstance abuse
DISEASE
initially admitted to OSH on [**2200-3-25**] for s/ptonic-clonic
seizure
DISEASE
resulting in a fall and broke right hiprequiring R hip ORIF on [**2200-3-31**]. It was felt that
seizure
DISEASE
wassecondary to benzo withdrawal as pt was taking 5 mg of Xanax tidat home. He was then to d/c'd to transitional care rehab on[**2200-4-2**] to be later admitted on [**2200-4-3**] for AMS/seizures.In the ED at OSH loaded with 1 gm dilantin 2 mg ativan and 2mg dilaudid and admitted. Per records pt not on benzos while atrehab. EEG from [**4-4**] and [**4-5**] showed no localizing
seizure
DISEASE
activity.On [**2200-4-6**] pt became lethargic tachypneic w/rr in 40's andhypoxic. He was also reportedly febrile (unknown temp). Hereceived one dose of CTX which resulted in a
skin rash
DISEASE
. He wasthen transferred to the ICU with concerns for
NMS
DISEASE
vs. sertoninsyndrome vs. benzo-withdrawal vs. infection/sepsis.ICU course at OSH notable for start of ativan gtt andpsychotropic meds including risperdal seroquel wellbutrinand xanaflex. WBC count at 11 Cr 4.4 LFTs wnl at that time.Dilantin level 7.7 at that time. Daily head CT's from [**4-4**] to[**4-6**] were all normal. During this time pt became
hyperkalemic
DISEASE
to 5.4 and acidotic with bicarb of 18. ABG on [**2200-4-6**] was7.2/24/72/16. Pt was then started on a bicarb gtt. Lactate was1.2 serum and urine tox unremarkable except for benzos. Pt wasROMI with enzymes during his course. TTE today showed preservedEF moderate AS/AI moderate
MR
DISEASE
elevated RV pressures of 91.Past Medical History:1)AVR in [**2190**] for Enterococcus
faecalis endocarditis
DISEASE
2)Cellulitis x 63) DM II diagnose in [**4-21**] treated with glipizide4)Polysubstance use (cocaine opiates benzos anabolicsteroids)5) H/O
pancreatitis
DISEASE
in [**2194**]6) Cluster HA's7) Neck and back
pain
DISEASE
- has been to musculoskeletal specialistas well as PT8)
Anxiety
DISEASE
9) ADHD/ADD10) Left pectoral and biceps tear s/p surgerySocial History:Recently divorced currently lives with girlfriend. Moved to[**Location (un) 86**] 6 months ago from [**State 5864**]. h/o IVDU. Unemployed.Family History:DM
Hyperlipidemia
DISEASE
Fibromyalgia (sister)Multiple staph
infections
DISEASE
DVT
DISEASE
Physical Exam:VS - 99.6 110/59 112 25-30 95%/3LNCGeneral - Somnolent awakens with loud voice and tactilestimulationHEENT - NC/AT PERRL EOMI. MM dryNeck - suppleChest - CTA-B no w/r/rCV - RRR s1 s2 normal Admission Date: [**2175-9-27**] Discharge Date: [**2175-9-28**]Date of Birth: [**2101-11-11**] Sex: MService: SURGERY
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 158**]Chief Complaint:rectal
bleeding
DISEASE
following prostate biopsyMajor Surgical or Invasive Procedure:1. prostate biopsy2. exam under anesthesia3. ligation of post-prostate biopsy
bleeding
DISEASE
History of Present Illness:The patient is a 73-year-old man who underwent a prostate biopsyin [**Hospital 159**] clinic complicated by immediate significant brightred
blood bleeding
DISEASE
. Attempts were made to stop the
bleeding
DISEASE
witha dilating Foley balloon and Surgicel packing without success.He was admitted for surgical management of
bleeding
DISEASE
.Past Medical History:
hyperlipidemia coronary artery disease prostate cancer gout
DISEASE
Social History:Retired as a waiter in a Chinese restaurant. Patient is anaccomplished poet who has published works in Chinese. Daughteris nurse. Tobacco none ETOH: None Drugs: NoneFamily History:non-contributoryPhysical Exam:VS T 98.5 HR 68 BP 91/52 RR 18 SpO2 98%RAAdmission Date: [**2195-10-6**] Discharge Date: [**2195-10-20**]Service: NMED
Allergies
DISEASE
:Naproxen / Diltiazem / PropranololAttending:[**First Name3 (LF) 5868**]Chief Complaint:
Dizziness
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Patient is an 85 year old woman with past medical history of
hypertension
DISEASE
hypercholesterolinemia and
vertebral aneurysm
DISEASE
whopresents with
dizziness
DISEASE
. She awoke on the morning of admissionwith sense of
dizziness
DISEASE
and
dysequilibrium
DISEASE
like things weremoving around her. The sensation was worsened with headmovements and present in all positions. She denied any
nausea
DISEASE
diplopia
DISEASE
or
neck pain
DISEASE
. When she walked felt unsteady and hadto hold onto things to steady herself. She then had developed a
pain
DISEASE
which she is unable to characterize further all over herhead that build up to [**9-1**] but is now [**5-2**]. She also complainedof
photophobia
DISEASE
but denied any visual speaking or swallowingdifficulties. Of note she did have a
cough
DISEASE
but no
fever
DISEASE
inpast week. She denied any recent
trauma
DISEASE
or neck manipulations.Her neighbor came over and then called 911Admission Date: [**2200-3-24**] Discharge Date: [**2200-4-5**]Date of Birth: [**2137-1-6**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Penicillins / Tetracycline / CodeineAttending:[**First Name3 (LF) 1283**]Chief Complaint:Dyspnea/Chest
pain
DISEASE
Major Surgical or Invasive Procedure:[**2200-3-24**] - Re-do sternotomy AVR (21mm St. [**Male First Name (un) 923**] mechanical)History of Present Illness:This 62 year old patient with previous coronary artery bypassgrafting in [**2180**] presented at this time with symptoms of chest
pain
DISEASE
and
dyspnea
DISEASE
on exertion. He was investigated and was foundto have residual disease in the obtuse marginal graft and alsosevere
aortic stenosis
DISEASE
and mild to moderate mitralregurgitation. He had no viable leg veins to be used asconduits and hence preoperatively the obtuse marginal veingraft was stented successfully and he was electively admittedfor aortic valve replacement with or without mitral valve repairor replacement.Past Medical History:
Coronary artery disease
DISEASE
s/p CABGx4 [**6-/2181**]CRI with acute creatinine rise post cardiac catheterizationMI [**2193**]
PVD
DISEASE
AF
DVT
DISEASE
Diabetes
DISEASE
HTN
DISEASE
Neuropathy/Retinopathy
DISEASE
Iron deficiency
anemia
DISEASE
Depression/Anxiety
DISEASE
s/p
Subdural hematoma
DISEASE
with evacuationMultiple PCI's
Atrial Flutter
DISEASE
ablation [**2190**]Multiple toe amputationsGreen Field Filter placements/p Right lower extremity bypassLeft saphenous vein harvest
Aortic stenosis
DISEASE
Social History:Lives with wife in [**Name (NI) 5871**] MA. Prior alcohol and
drug abuse
DISEASE
(pills/cocaine). He is disabled. Smoked [**12-2**] ppd stopping in[**2195**].Family History:2 uncles died of [**Name (NI) 5290**] at age 57 and 60.Physical Exam:52 SB BP (R) 132/70 (L) 140/74 98%
RA
DISEASE
Weight 230 73Admission Date: [**2201-1-29**] Discharge Date: [**2201-2-19**]Date of Birth: [**2137-1-6**] Sex: MService: MEDICINE
Allergies
DISEASE
:Penicillins / Tetracycline / CodeineAttending:[**First Name3 (LF) 898**]Chief Complaint:
gastro-intestinal bleed
DISEASE
Major Surgical or Invasive Procedure:esophagogastroduodenoscopy x3capsule endoscopy x2PICC line placementHistory of Present Illness:The patient is a 64 M with CAD s/p 4V-CABG [**2180**] AVR [**2200-3-24**] [**Male First Name (un) 923**] mechanical valve
HTN
DISEASE
AFIB
DM2
DISEASE
transferred from[**Hospital 5871**] Hospital to [**Hospital1 18**] ICU for workup of
acute GIB
DISEASE
. Admittedto [**Location (un) 5871**] on [**1-11**] considering replacing his mechanical withporcine valve but there he had CP and
dizziness
DISEASE
per GI consultnote there but was found to have INR 5 and Hct 18. Over 2weeks he received 14 U RBC Hct up to 30s but then drifteddown. Did capsule limited by food but possibly
melena
DISEASE
EGDnegative
bleeding
DISEASE
scan negative found blood trickling downfrom terminal ileum. Patient did not notice any blood but blindin R eye and mostly blind in L eye. Patient was transferred to[**Hospital1 18**] for further evaluation and potential replacement ofmetallic aortic valves with porcine valve that would not requireanti-coagulation.Past Medical History:
Coronary artery disease
DISEASE
s/p CABGx4 [**6-/2181**] last cath [**1-/2200**]: Three vessel coronary arterydisease. Successful stenting of the SVG-OM with drug-elutingstent.CRI with acute creatinine rise post cardiac catheterizationMI [**2193**]
PVD
DISEASE
AF
DVT
DISEASE
Diabetes
DISEASE
HTN
DISEASE
Neuropathy/Retinopathy
DISEASE
Iron deficiency
anemia
DISEASE
Depression/Anxiety
DISEASE
s/p
Subdural hematoma
DISEASE
with evacuationMultiple PCI's
Atrial Flutter
DISEASE
ablation [**2190**]Multiple toe amputationsGreen Field Filter placements/p Right lower extremity bypassLeft saphenous vein harvest
Aortic stenosis
DISEASE
Social History:Lives with wife in [**Name (NI) 5871**] MA. Prior alcohol and
drug abuse
DISEASE
(pills/cocaine). He is disabled. Smoked [**12-2**] ppd stopping in[**2195**]. Does not drink or use drugs at this time.Family History:2 uncles died of [**Name (NI) 5290**] at age 57 and 60.Physical Exam:VS: 97.0 / 100/60 / 81 / 20 / 97%
RA
DISEASE
Gen: sleeping but arousable NAD w/o
complaint
DISEASE
HEENT: R eye completely blind L eye partially blind. L PERRL LEOMI oropharynx clear w/o
erythema mouth
DISEASE
with poor dentitionNeck: supple no LAD JVD 6Chest: CTA B well-healed sternotomy scarCV: Irregularly irregular S1 S2 with with mechanical click. NomurmursAbd: Soft obese ND NT Admission Date: [**2112-6-7**] Discharge Date: [**2112-6-22**]Date of Birth: [**2038-6-4**] Sex: MService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 5880**]Chief Complaint:s/p fallMajor Surgical or Invasive Procedure:[**6-8**]: attempted laminectomy (aborted for
bleeding
DISEASE
)[**6-10**]: C4-T3 laminectomy C4-T1 fusion[**6-14**]: C4-C7 anterior fusionHistory of Present Illness:74M on coumadin for a fib s/p
unwitnessed
DISEASE
fall down severalflights of stairs Admission Date: [**2128-6-16**] Discharge Date: [**2128-6-20**]Date of Birth: [**2059-3-29**] Sex: FService: PLASTIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 5883**]Chief Complaint:Asymmetric breast tissue as a result of mastectomy secondary to
breast cancer
DISEASE
Major Surgical or Invasive Procedure:1. Left delayed deep
inferior epigastric
DISEASE
perforator flap ([**Last Name (un) 5884**]flap).2. Harvest of deep
inferior epigastric artery
DISEASE
and vein pedicleat pelvis.3. Autologous fat grafting vascular pedicle.History of Present Illness:The patient is a 68-year-old woman with a history of left breast
cancer
DISEASE
. She underwent a mastectomy followed by chemotherapy andradiation therapy. Shefinished her radiotherapy in [**2126-8-29**]. She presented to Dr[**First Name (STitle) **] interestedin breast reconstruction and was admitted to the hospital for[**Last Name (un) 5884**] (deep
inferior epigastric
DISEASE
perforator) flap reconstructionto her left chest wall.Past Medical History:1. Left
breast cancer
DISEASE
status post treatment with Taxol andHerceptin. Initially underwent left partial mastectomy butreturned for left modified radical mastectomy in [**5-1**].2.
Hypertension
DISEASE
3. Status post excision of ganglion cyst in handSocial History:The pt is married and lives with her husband. Homemaker.Emigrated from [**Country 2045**] Admission Date: [**2129-9-21**] Discharge Date: [**2129-9-21**]Date of Birth: [**2059-3-29**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 5893**]Chief Complaint:
Hypothermia hypotension lactic acidosis
DISEASE
Major Surgical or Invasive Procedure:Intubation femoral CVL femoral arterial lineHistory of Present Illness:Patient is a 70 year old female with past medical history of
coronary artery disease hypertension CVA
DISEASE
and
breast cancer
DISEASE
who was recently discharged from [**Hospital1 18**] on [**9-16**]. Per report fromthe emergency room physicians her daughter went to visit thepatient today and noted the patient was cold breathing fastand felt unwell. EMS was called and upon arrival the patientwas noted to be
tachypneic
DISEASE
with a respiratory rate to the 40'scold sweaty and
hypotensive
DISEASE
with a blood pressure of 70/palp.EMS was unable to obtain a temperature or start an IV in thefield..Upon arrival to [**Hospital1 18**] ED patient was noted to be
tachypneic
DISEASE
and was placed on a non-rebreather. The ED staff had a difficulttime obtaining a blood pressure (erratic and felt to beerroneous readings of 190's obtained) and ultimately a mannualcuff provided [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1131**] of systolic of 85. Again it wasdifficult to place a peripheral IV so a left EJ was placed.Ultimately a femoral central line was placed as with herpersistent
tachypnea
DISEASE
a neck line was felt unsafe. Her breathingimproved to a rate in the 20's and she was placed on nasalcannula oxygen with a saturation in the 90's. She received threeliters of intravenous fluid. A chest x-ray was felt to possiblybe consistent with
pneumonia
DISEASE
so she was given levofloxacinzosyn and vancomycin to cover for possible aspiration and
hospital-acquired
DISEASE
pathogens given her recent stay. Of note sheremained hypothermic and a rectal probe was unable to read atemperature. With warm blankets her temperature improved to 92rectally at time of transfer. Her labs were notable for alactate of 9.5 troponin at her baseline (0.06) and a bump inher creatinine to 2.3 (previously 1.4)..Upon arrival to the floor patient denies any discomfort or
pain
DISEASE
but states she feels cold. She cannot provide any detailsregarding the events leading to hospitalization.Past Medical History:
Dyslipidemia
DISEASE
Hypertension
DISEASE
Recent Inferior STEMI ([**6-/2129**])Left
breast cancer
DISEASE
s/p modified radical mastectomy [**2125**]Admission Date: [**2129-8-8**] Discharge Date: [**2129-8-9**]Date of Birth: [**2075-2-14**] Sex: MService: MEDICINE
Allergies
DISEASE
:IodineAdmission Date: [**2188-10-28**] Discharge Date: [**2188-11-4**]Date of Birth: [**2120-4-18**] Sex: MService: CSUHISTORY OF PRESENT ILLNESS: This is a 68-year-old malepatient with a long history of
coronary artery disease
DISEASE
status post multiple percutaneous interventions in past 35years with his last intervention in [**2187-4-29**] who presentedto an outside hospital on the morning of [**2188-10-28**] withcomplaints of
chest pain
DISEASE
at rest no troponin leak at thatoutside hospital who was transferred to the [**Hospital1 18**] for cathshowing severe 3VD with a left main stenosis of 60 percentLAD 50-60 percent left circ 80 percent RCA 90 percentdistal involving the PDA who was referred at this time forcoronary artery bypass grafting.PAST MEDICAL HISTORY: Coronary
artery disease
DISEASE
status post 6-7 stents in the past.
Hyperlipidemia
DISEASE
.
Gout
DISEASE
.
Gastroesophageal reflux disease
DISEASE
.
Depression
DISEASE
.PAST SURGICAL HISTORY: Right carotid endarterectomyapproximately 5 years ago.Appendectomy as a child.ALLERGIES: No known
drug allergies
DISEASE
.MEDS PRIOR TO ADMISSION:1. Lescol 80 mg once daily.2. Folate 1 mg once daily.3. Prevacid 30 mg once daily.4. Colchicine 0.6 mg [**Hospital1 **].5. Zetia 10 mg once daily.6. Wellbutrin SR 150 mg [**Hospital1 **].7. Cardizem CD 240 mg once daily.8. Colace 100 mg [**Hospital1 **].9. Allopurinol 100 mg once daily.10.Provigil 100 mg once daily.11.Imdur 30 mg q am and 15 mg q pm.12.Plavix 75 mg once daily.13.Ecotrin 325 mg once daily.14.Diovan/HCTZ 160/12.5 once daily.15.Vitamin B6 50 mg once daily.PHYSICAL EXAM ON PRESENTATION: Height 5 feet 8 inches tallweight 250 pounds. Vital signs: Blood pressure 118/66heart rate 54 and sinus rhythm temp 97.1. General: Lyingflat in bed in no acute distress. Neuro: Alert and orientedx 3 appropriate. Respiratory: Clear to auscultation.Cardiovascular: Regular rate and rhythm S1 S2 II/VIsystolic ejection murmur loudest at the apex. GI: Softobese nontender nondistended with positive bowel sounds.Extremities: Warm and well-perfused no
edema
DISEASE
novaricosities with good distal pulses.LABS ON ADMISSION: WBC 5.7 hematocrit 44.3 platelets 156PT 13.0 PTT 26.5 INR 1.1 sodium 137 potassium 3.7chloride 100 bicarb 28 BUN 16 creatinine 0.9 glucose 153ALT 42 AST 27 alk phos 70 total bili 0.5 albumin 4.0.SUMMARY OF HOSPITAL COURSE: As above the patient wasadmitted on [**2188-10-28**] and proceeded to the Cardiac Cath Labshowing severe 3VD and was referred for coronary arterybypass grafting. He underwent a preop evaluation and wascleared for CABG and proceeded to the operating room on[**2188-10-30**] and underwent coronary artery bypass grafting x 4with Dr. [**Last Name (STitle) **] with a LIMA to the LAD saphenous vein graftto the OM left PDA and right PDA. He was transferred to theCardiac Surgery Recovery Room
AV-paced
DISEASE
with a rate of 88mean arterial pressure of 76 and CVP of 14. He wassustained on Neo-Synephrine and propofol drips. Hisunderlying rhythm initially was a
sinus bradycardia
DISEASE
with arate in the 30's.Postoperative day 1 was significant for successful extubationand return of his heart rate to 62 in a normal sinus rhythm.On postoperative day 4 the rest of his intravenousmedications were discontinued and his Foley catheter wasalso discontinued and he was transferred to the inpatientfloor for continued care.Postoperative day 3 and 4 were also uneventful with heartrate continuing in sinus rhythm not requiring any cardiacpacing. His pacing wires were thus DC'd and his usual medswere resumed. Mr. [**Known lastname 3075**] was followed by the physicaltherapy team throughout his recovery and on [**2188-11-3**] metall goals of therapy and was DC'd from a physical therapystandpoint.On postoperative day 5 [**2188-11-4**] Mr. [**Known lastname 3075**] was found tobe medically ready for home and was discharged home withvisiting nurses to follow.CONDITION ON DISCHARGE: Vital signs: Temp 97 pulse 62 insinus rhythm BP 130/Admission Date: [**2196-4-27**] Discharge Date: [**2196-5-3**]Service: CARDIOTHORACIC
Allergies
DISEASE
:AtenololAttending:[**First Name3 (LF) 5790**]Chief Complaint:Right upper lobe massMajor Surgical or Invasive Procedure:[**2196-4-27**]: Right thoracotomyAdmission Date: [**2167-4-9**] Discharge Date: [**2167-5-3**]Date of Birth: [**2086-6-6**] Sex: FService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 598**]Chief Complaint:
trauma
DISEASE
transfer from OSH s/p unwitness fall right rib
fractures
DISEASE
right
pneumothorax
DISEASE
spinal
compression fractures
DISEASE
Major Surgical or Invasive Procedure:placement of right chest tubes done at bedside (x3)pleurodesis right lung done at bedsideHistory of Present Illness:Patient is an 80 year old patient who experienced a witnessedfall onto concrete. She had no recollections of the events. Shecraweled into the house and was found by her son. At that timeshe was in
respiratory distress
DISEASE
and complained of right chest
pain
DISEASE
. She was brought to the [**Hospital3 628**] and wassubsequently transferred here. She was found to have a
pneumothorax
DISEASE
on the right and chest tubes were placed at OSH.Patient had
small abrasions
DISEASE
on the right forearm and right knee.She was hemodynamically stable on arrival.Patient was also found to have
compression fractures
DISEASE
of L4 L5T6 T7 T9 T12.Patient has no prior history of
trauma
DISEASE
.Past Medical History:PMH:
COPD
DISEASE
on O2 at home ranges from 2-2.5 LNC
hypertension
DISEASE
hyperlipedemia
DISEASE
Dementia
DISEASE
Depression
DISEASE
Osteoporosis
DISEASE
PSH
DISEASE
:surgical excision of [**Last Name (un) 5902**] neuromaSocial History:- patient lives with son- is retired- smokes 1 pack of cigarettes a day- denies etoh and drug useFamily History:non-contributoryPhysical Exam:PE:VS: Tm 98.8 HR 78 BP 132/76 RR 20 O2 sat 98% on 2L/min NCgen: WA/WD NADCV: RRR no m/r/gpulm: CTA b/labdomen: Admission Date: [**2175-9-29**] Discharge Date: [**2175-10-4**]Date of Birth: [**2101-11-11**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 165**]Chief Complaint:
angina
DISEASE
and STEMIMajor Surgical or Invasive Procedure:[**2175-9-29**] cardiac cath[**2175-9-29**] CABG X5 (LIMA to LAD SVG to DIAG SVG to OM1Admission Date: [**2116-6-1**] Discharge Date: [**2116-6-10**]Date of Birth: [**2037-5-2**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 689**]Chief Complaint:Bright red
blood loss
DISEASE
per rectumMajor Surgical or Invasive Procedure:ColonoscopyHistory of Present Illness:Ms. [**Known lastname 5903**] is a 79 yo female with h/o CAD
PVD DM2 CKD
DISEASE
and
diverticulosis
DISEASE
who presented on [**2116-6-1**] with BRBPR on multipleBMs starting the day of arrival. She had no
cramping pain
DISEASE
nausea
DISEASE
or other symptoms at the time. VS were stable in theED and Hct was noted to be dropping from 35 recently to 30 andthen to 27 with continued bloody BMs.ROS was negative for
fevers chills
DISEASE
unintentional weightchanges orthopnea
chest pain dyspnea abdominal pain
DISEASE
easing
bruising dysuria
DISEASE
and
rashes
DISEASE
.Past Medical History:- CAD s/p CABG [**2107**]- PVD-
CKD
DISEASE
stage III-
HTN
DISEASE
-
DM2
DISEASE
complicated by
retinopathy nephropathy
DISEASE
- diverticulosisAdmission Date: [**2117-3-30**] Discharge Date: [**2117-4-3**]Date of Birth: [**2037-5-2**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 5510**]Chief Complaint:
Lower GIB
DISEASE
Major Surgical or Invasive Procedure:4 units of packed red blood cellsHistory of Present Illness:79 year old female with a past history of
hypertension
DISEASE
type 2
diabetes CAD
DISEASE
s/p CABG x 4 and history of lower gastrointestinal
bleeding
DISEASE
of unclear source who presents to the emergency roomwith 4 days of Admission Date: [**2166-10-14**] Discharge Date: [**2166-10-20**]Date of Birth: [**2137-3-5**] Sex: FService: OBSTETRICS/GYNECOLOGY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Doctor First Name 5911**]Chief Complaint:Menometrorrhagia
pelvic pain
DISEASE
.Major Surgical or Invasive Procedure:1. Abdominal Supracervical hysterectomy2. Exploratory laparotomy and
hematoma
DISEASE
evacuation3. Cystoscopy & retrograde ureterogramHistory of Present Illness:The patient is a 29-year-old G5 P1-1-3-2 thin African-Americanfemale with a large symptomatic
fibroid
DISEASE
uterus complaining ofprolonged
menometrorrhagia
DISEASE
as well as severe
pelvic pain
DISEASE
whopresented with severe
anemia
DISEASE
with a hematocrit of 25.The patient was being evaluated by her PCP for suspectedunderlying
thalassemia
DISEASE
. Iron studies revealed severe
iron-deficiency anemia
DISEASE
however the patient was not compliantwith p.o. iron. Given the source of
anemia
DISEASE
was likely due to herfibroid uterus the patient was transfused 2 units of packed redblood cells 1 day preoperatively as well as 125 mg of FerrlecitIV to try toimprove her iron stores and blood supply. The patient wasoffered to delay the surgery to improve her iron stores withp.o. iron however the patient had been noncompliant anddeclined this option. The risks of
infection
DISEASE
with bloodtransfusion as well as the side effects of blood transfusionwere discussed with the patient at length. The patient wascounseled extensively and she opted for the preop transfusionand IV iron and to proceed with the surgery. Even after thepatient was transfused the 2units of packed red blood cells herpost-transfusion heamtocrit was only 27 since she continued to
bleed
DISEASE
heavily from her
uterine fibroids
DISEASE
since the last HCT of25.Past Medical History:PMH: She states that she is otherwise healthy withthe exception of this left lower extremity swelling episodewhich was not painful unclear etiology. She is currently notbeing evaluated as she was not compliant with followup with herPCP after the emergency room visit.PAST SURGICAL HISTORY:1. D&C x2 for elective termination of pregnancies.2. Her
IUFD
DISEASE
at 6 months was successfully delivered vaginallywith an induction of
labor
DISEASE
.Social History:Admits to smoking 3 cigarettes per day for the last 2 years.Also admits to drinking occasionally 3 drinks per week onFridays. Denies any recreational drug use or IV drug use. Sheis currently employed as an administrative assistant at [**Hospital1 **] atthe Radiation Oncology Department. She is single notcurrently dating lives with her mother. Denies a history of
sexual abuse
DISEASE
and domestic violence.Family History:Mother maternal aunt and maternal niece with history of
breast
cancer
DISEASE
. She has a sister who is alive and well without
breast
cancer
DISEASE
.
Denies
DISEASE
a family history of
ovarian uterine
DISEASE
cervicalor
vaginal cancer
DISEASE
or
colon cancer
DISEASE
or anyother
cancers
DISEASE
in the family. Also denies family history of
diabetes heart disease
DISEASE
or
hypercholesterolemia
DISEASE
. Paternalgrandmother and sister both suffer from
hypertension
DISEASE
. Deniesany other significant family medical history.Physical Exam:Vitals T:98.6F HR:60 RR:16GEN: NADCVS: RRRResp: CTABABD: (post-op) soft non-tender Admission Date: [**2135-4-19**] Discharge Date:Date of Birth: [**2064-10-26**] Sex: FService: CARDIOTHORACIC SURGERYHISTORY OF PRESENT ILLNESS: The patient is a 70-year-oldfemale with known history of
coronary artery disease
DISEASE
referredfor outpatient cardiac catheterization secondary to apositive stress test. The patient had a PTCA stent to theright coronary artery on [**2131-6-2**]. Cardiac catheterizationin [**2132-4-2**] showed 50% right coronary artery with a patentstent 50% mid left anterior descending 75% circumflex 95%OM and 70% diagonal.The patient had been doing well and denied any
chest pain
DISEASE
.She did report having
dyspnea
DISEASE
on exertion over the past 1-2months and had been getting
shortness of breath
DISEASE
from walkingabout a quarter of a mile. She also had recently beenfeeling very tired in general.On [**2135-4-18**] the patient had an ETT Thallium withreport which showed that thepatient exercised for 4Admission Date: [**2135-4-19**] Discharge Date: [**2135-5-4**]Date of Birth: [**2135-10-27**] Sex: FService:HISTORY OF PRESENT ILLNESS: The patient is a 70 year-oldfemale with a history of
coronary artery disease
DISEASE
status postpercutaneous transluminal coronary angioplasty stent of theright coronary artery in 5/99 and catheterization in 3/[**2132**].She was doing well without
chest pain
DISEASE
but had
dyspnea
DISEASE
onexertion for one to two months and recently felt fatigued.She had a positive ETT and thallium test on [**4-18**] whichrevealed 2 to [**Street Address(2) 2051**]
depressions
DISEASE
inferolaterally and chest
pain
DISEASE
at 4.5 minutes of exercise. She underwent a cardiaccatheterization at [**Hospital1 69**] on[**4-19**] which showed good ejection fraction and trace mitralregurgitation of left ventricular short LMCA two serial 60to 70% lesions in the mid left anterior descending coronaryartery 85% at the origin of the large diagonal artery 60%origin at the high diagonal almost to the ramus 95% lesionof the origin of the obtuse marginal one 95% LCX afterobtuse marginal one effecting more distal second obtusemarginal distal
AV groove LCX occlusion
DISEASE
before
PLV branch
DISEASE
.Mild mid right
coronary artery lesion
DISEASE
90% lesion just beforevery large PDA which is collateral source to
LCX
DISEASE
and leftanterior descending coronary artery diagonal territory.PAST MEDICAL HISTORY:1. Coronary artery disease status post percutaneoustransluminal coronary angioplasty stent of right coronaryartery in 5/99. Status post catheterization in 3/[**2132**].2.
Hypertension
DISEASE
.3.
Meniere's disease
DISEASE
.4. Hysterectomy.5. Transient ischemic attack 25 years ago.6. High cholesterol.HOME MEDICATIONS:1. Ecotrin 25 mg po q.d.2. Lopressor 100 mg po b.i.d. and 50 po q.h.s.3. Diovan 160 mg po q day.4. Lipitor 40 mg po q day.5. Premarin .6 mg po q.d.6. Meclozine 12.5 mg po q.d.FAMILY HISTORY: Positive for
coronary artery disease
DISEASE
.SOCIAL HISTORY: She is and has been always a nonsmoker. Noalcohol. The patient lives alone.ALLERGIES: Diuril.PHYSICAL EXAMINATION: In general the patient is in no acutedistress. AVSS. HEENT normocephalic atraumatic. Pupilsare equal round and reactive to light. Extraocularmovements intact. Oropharynx benign. Neck supple. Fullrange of motion. No
lymphadenopathy
DISEASE
or
thyromegaly
DISEASE
.Carotids 2Admission Date: [**2135-4-19**] Discharge Date: [**2135-5-5**]Date of Birth: [**2064-10-26**] Sex: FService:ADDENDUMThe patient was kept one more night secondary to small apical
pneumothorax
DISEASE
after chest tube placement. The chest tube wasbriefly put back to suction and then discontinued. Apost-discontinuation chest x-ray showed no
pneumothorax
DISEASE
. Sheis being discharged today in good condition. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **] M.D. [**MD Number(1) 3113**]Dictated By:[**Last Name (NamePattern1) 1332**]MEDQUIST36D: [**2135-5-5**] 09:26T: [**2135-5-5**] 09:24JOB#: [**Job Number 5921**]Admission Date: [**2141-9-27**] Discharge Date: [**2141-9-28**]Service: SURGERY
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 1556**]Chief Complaint:
RUQ pain
DISEASE
.Major Surgical or Invasive Procedure:None.History of Present Illness:[**Age over 90 **]M with multiple medical co-morbitities including
Afib
DISEASE
BPH s/pTURP x 3 CRI who presented to the ED this morning after beingfound short of breath in his nursing home with
RUQ pain
DISEASE
. Onarrival at [**Hospital1 18**] ED patient was found have RR in the 50's andSBP in the 60s. Patient was emergently intubated and started onneo gtt and levophed gtt. ED ordered a CT scan which showedlikely
gangrenous cholecystitis
DISEASE
with intrabdominal free air.Surgery was emergently consulted for further management.Past Medical History:
Dementia Hypertension Chronic kidney disease
DISEASE
BPH withoverflow
incontinence
DISEASE
Urinary retention Prostate cancer
Inguinal hernia Iron deficiency anemia UGI bleed Glaucoma
DISEASE
Stasis dermatitis
DISEASE
and superficial ulcerations
Lymphedema AFib
DISEASE
PSH
DISEASE
: TURP [**3-21**]Social History:Lives at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. They provide meals. Denies smokingsocial drinking. Used to be a designer of clothes had his owncompany. Per reports from [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] unable to walk on hisown and requires assistance for the majority of his other ADL's(but is able to use the bedpan and feed himself).Family History:Patient unsure age parents passed away. Has many siblings (7 or8) four of whom are still alive.Physical Exam:T 99.8 P 90 BP 120/70 ACV 450 x 20 .50 FIO2 on neo gtt Admission Date: [**2167-1-30**] Discharge Date: [**2140-3-14**]Date of Birth: [**2125-10-11**] Sex: FService:HISTORY OF PRESENT ILLNESS: [**Known lastname 5923**] is a 41-year-old femalewith past medical history of questionable
chronic obstructive
pulmonary disease
DISEASE
and
asthma
DISEASE
with two recent hospitalizationfor
asthma
DISEASE
/
chronic obstructive pulmonary disease
DISEASE
flarescomplicated by
pneumonia
DISEASE
. Patient presents with five days of
URI symptoms sore throat
DISEASE
and
fatigue
DISEASE
three days of
shortness of breath
DISEASE
with inhaler use with moderate relieftwo day history of
cough dry
DISEASE
and nonproductive andsubjective
fevers
DISEASE
and
chills
DISEASE
. Patient denies
myalgias
DISEASE
headache
DISEASE
chest pain rash diarrhea
DISEASE
abdominal discomfortor
hemoptysis
DISEASE
. Current symptoms are identical to prioradmission. Patient's last admission was on [**11-15**]. Patienthas one lifetime history of intubation. Patient had a lungbiopsy in [**9-15**] past reports suggestive of
interstitial
pulmonary fibrosis
DISEASE
.On presentation to the Emergency Department patient had atemperature of 101.9 F heart rate of 126 blood pressure156/85 breathing rate of 28 saturating at 83% on room air.Patient was put on oxygen. Patient received a chest x-raywhich showed questionable early left lower lobe infiltratewith
atelectasis
DISEASE
. EKG showed patient in sinus tach with poorR wave progression left axis deviation no signs of
ischemia
DISEASE
. Patient was started on antibiotics steroids nebsand admitted.PAST MEDICAL HISTORY:1. Interstitial pulmonary
fibrosis
DISEASE
.2. Adult onset
asthma
DISEASE
with one lifetime intubation multiplehospitalizations.3. History of
VRE
DISEASE
and MRSA.4. Schizoaffective disorder.5. Depression.6. Multiple suicide attempts.7.
Temporal lobe epilepsy
DISEASE
.8. Meningitis.9. History of positive PPD status post six month treatmentwith INH and Rifampin.10.
Gastroesophageal reflux disease
DISEASE
.11. History of TDs in the setting of ETOH withdraw.12. Exploratory laparotomy for
abdominal mass
DISEASE
versus uterine
cyst
DISEASE
.13. Noninsulin dependent
diabetes mellitus
DISEASE
.ALLERGIES:1. Patient has
insensitivity
DISEASE
to Codeine which gives her GIupset.2. True
allergy
DISEASE
to Penicillin for which she gets a
rash
DISEASE
.3. Erythromycin for which she also gets a
rash
DISEASE
.MEDICATIONS:1. Prozac 60 mg p.o. q. day.2. Neurontin 1200 mg p.o. t.i.d.3. Clozaril 100 mg q. AM 400 mg q. PM.4. Flovent two puffs b.i.d.5. Albuterol nebs p.r.n.6. Risperdal 2 mg p.o. q.h.s.SOCIAL HISTORY: Patient smokes one to two packs ofcigarettes per day and has a history of medical noncomplianceand poor follow up. Patient has been sober for greater than10 years. Also prior use of LSD cocaine and heroin use butnone in the recent past. Patient lives alone.PHYSICAL EXAMINATION: On arrival to the medical floor thepatient had a temperature of 98.3 F blood pressure 120/68pulse of 100 respirations 22 saturating 94% on 10 litermask. In general patient is an obese white female in milddistress able to speak in full sentences. Normocephalicatraumatic. Pupils equal round and reactive to light.
Extraocular movements
DISEASE
intact. Oropharynx is clear. Neck wassupple without
tenderness
DISEASE
or
rigidity
DISEASE
. No jugular venousdistention was appreciated. Lungs: Decreased breath soundsin the right base with mild
wheezing
DISEASE
. Cardiovascularly:Patient was tachycardic S1 S2 no murmurs. Abdomen wasobese soft nontender nondistended with normoactive bowelsounds. Extremities: 1Admission Date: [**2121-5-18**] Discharge Date: [**2121-5-27**]Date of Birth: [**2086-12-16**] Sex: FService: MEDICINE
Allergies
DISEASE
:Penicillins / Codeine / Nsaids / LevaquinAttending:[**First Name3 (LF) 1711**]Chief Complaint:
Shortness of Breath
DISEASE
Major Surgical or Invasive Procedure:defibrillationHistory of Present Illness:34 yo woman with h/o
hypertrophic CMY
DISEASE
multifocal atrial
tachycardias
DISEASE
s/p failed PVI [**3-21**] c/b pericardial tamponade cwindow c/b PEA arrest x 45 minutes [**3-21**] with temporary CVVHDand recent admission for SOB treated for
volume overload
DISEASE
whowas admitted with chief complaint of
shortness of breath
DISEASE
and
chest pain
DISEASE
. Initial vitals in ED showed T 97 HR 55 BP 124/66RR 19 with o2 sat 100% on 4L. Pt. being evaluated by residentin ED denying CP when she acutely c/o
dyspnea
DISEASE
and was noted tohave wide complex rhythm on tele and lost pulse. Given 2 rdsepi 1 rd atropine 2 rds bicarb/ca chloride/insulin/D50 forpresumed
hyperkalemia
DISEASE
as initial EKG showed sine wave pattern.Also given 2L IVFs. She was coded for 30 minutes after which sheregained pulse and EKG showed NSR with wide complex with RBBB.Initial BP 202/68. She then developed wide complex ventricular
tachycardia
DISEASE
with BP 68/p for which she was defibrillated X 1200J and started on dopamine. At that point she returned to NSRand was quickly weaned off dopamine gtt..She had non-sterile R femoral line placed for access. Initiallabs (during code) showed K 5.5 on ABG (unclear if before orafter tx. for
hyperkalemia
DISEASE
) with ABG of 6.92/63/50. Bedside TTEwithout
pericardial effusion
DISEASE
. CXR showed new RAdmission Date: [**2121-6-14**] Discharge Date: [**2121-6-16**]Date of Birth: [**2086-12-16**] Sex: FService: MEDICINE
Allergies
DISEASE
:Penicillins / Codeine / Nsaids / LevaquinAttending:[**First Name3 (LF) 1711**]Chief Complaint:transfer from [**Hospital1 1474**] with rapid
atrial rhythm hypotension
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:This is a complicated 34 year old woman with hypertrophic
nonobstructive cardiomyopathy atrial tachyarrhythmias
DISEASE
PVI forAF complicated by R
atrial perforation
DISEASE
and clot in pericardiumwith recent
VF arrest
DISEASE
with prolonged CPR and subsequentadmission to [**Hospital1 18**] [**Date range (1) 5932**]. The patient was discharged to homeon [**5-27**] and did well for about one week per her report. She thendeveloped increased
lower extremity edema
DISEASE
bilaterally as well asleft hand
swelling
DISEASE
per her report. She felt that she might bevolume overloaded so she presented to [**Hospital 1474**] Hospital on [**6-3**].States she was minimally active (using wheelchair/bedsidecommode) but she was trying to be as active as possible.On admission to [**Hospital1 1474**] INR was supratherapeutic 5.8 whichincreased to 7.2 on [**6-5**]. She was treated with variousmedications (zaroxolyn lasix IV & PO) for
volume overload
DISEASE
. CTof the chest demonstrated large right-sided
pleural effusion
DISEASE
andright-sided infiltrate. On [**6-9**] right-sided thoracentesis wasperformed with removal of 1300 cc fluid. Initially treated withceftriaxone/azithromycin for
pneumonia
DISEASE
changed toazithromycin/cefuroxime on [**6-6**]. She was diuresed Admission Date: [**2175-7-11**] Discharge Date: [**2175-7-29**]Date of Birth: [**2114-2-8**] Sex: MService:HISTORY OF PRESENT ILLNESS: This is a 61-year-old male witha past medical history significant for right upper lobe smallcell cancer stage III status post chemotherapy andradiation status post right upper lobe sleeve resection[**6-19**] also with past medical history significant for
diabetes
DISEASE
mellitus hypertension prostate cancer
DISEASE
status post radicalprostatectomy GERD
TIA
DISEASE
15 years ago
gout
DISEASE
and
COPD
DISEASE
. Thepatient has no known
drug allergies
DISEASE
. The patient is statuspost right upper lobe lung sleeve resection on [**6-19**] for small
cell lung cancer
DISEASE
. The patient was discharged home doing welluntil four days prior to admission when he presented to theEmergency Room with
shortness of breath
DISEASE
and
fevers
DISEASE
. Thepatient was given Levaquin and was then discharged homeagain. He continued having
shortness of breath
DISEASE
andproductive
cough
DISEASE
. He was admitted [**7-11**] for a follow-upbronchoscopy during which time they found a right middle lobeobstruction secondary to
swelling
DISEASE
. After the procedure thepatient had
shortness of breath
DISEASE
with an oxygen saturation of88 as well as
rigors
DISEASE
and
chills
DISEASE
. The patient was also foundto have poor color. The patient's O2 saturation improved.Chest x-ray was obtained and the patient was admitted. Thepatient underwent surgery [**2175-7-15**]. The patient underwentcompletion pneumonectomy bronchoscopy and serratus flapclosure of right main stem bronchus.Postoperative day #1 the patient was afebrile with heart rateof 56 blood pressure 104/56 satting at 99%. Chest tubeoutput 500 cc. Last gas 7.33 56 152 31 and 100%. On examlungs were clear to auscultation bilaterally. Incisiondressings were clean dry and intact. Heart was regular rateand rhythm. Abdomen was soft nontender non distended.Extremities had no
swelling
DISEASE
. White count 13.4 hematocrit38.5 platelet count 394000 potassium 4.8 BUN 13creatinine .6 with glucose of 188 magnesium 1.8 and CPK of1410. Plan was to wean the oxygen and check an ABG later onand continue the pneumonectomy tube. To check an EKG becauseof the EKG change this morning in which patient had STsegment elevations undergo rule out MI protocol.Postoperative day #2 the patient had no events over the last24 hours patient remained afebrile. Heart rate 60 normalsinus rhythm blood pressure 105/58 satting at 97% on fourliters last gas 7.39 52 96 33. Laboratory data revealedwhite count 13.2 hematocrit 33.8 platelet count 322000 PT12.9 PTT 25.7 INR 1.1 potassium 4.7 BUN 15 creatinine .5with glucose 158 and magnesium 1.7. CK 840. Chest x-raypending. Physical exam was benign. Plan was to administerLasix today after transfer to the floor. Infectious diseasecame by to see the patient postop day #2 as well because theywere requested to recommend an antibiotic for the rightinfiltrate to prevent the possibility of a postoperative
empyema
DISEASE
. Their recommendation was to continue with thecurrent IV antibiotics. Clindamycin and Ceftriaxone will bepresent. In the remote chance of
postoperative infection
DISEASE
empyema
DISEASE
these antibiotics will be present in the cavity andalso by peripheral circulation.Postoperative day #3 events over the last 24 hours include
atrial fibrillation
DISEASE
. Patient mildly
febrile
DISEASE
at 99.2 heartrate 57 and sinus rhythm blood pressure 102/42 respirations14 satting at 97% on four liters last gas 7.47 46 86 348 and 97%. White count 10.9 hematocrit 31.5 platelet count331000 INR 1.1 PTT 28 potassium 3.9 BUN 14 creatinine.5 glucose 141. Physical exam was benign. Plan was tocheck the PT PTT and to get a chest x-ray today and tocontinue 20 mg of Lasix. ID came by to see the patient againtoday at which time they stated that the patient is alreadyon broad coverage for the
lung abscess
DISEASE
. Strep and staffimproving the tubes will be discontinued after theantibiotics. Follow-up of sensitivities on the culture andanticipate a three week course of antibiotics.Postoperative day #4 events overnight include a bronchoscopywhich was negative for
fistula
DISEASE
. Stump was intact positivesecretions. The patient remained afebrile with a heart rateof 57
sinus rhythm sinus brady
DISEASE
. Blood pressure 136/68satting at 100% on 4 liters nasal cannula. White count 8.8hematocrit 29.8 platelet count 375000 cultures from [**7-15**]grew out streptococcus coag positive staph. Physical examwas benign. ID again came by to see the patient at whichtime they stated that they were awaiting final staph aureussensitivities before providing the direction of therapy.Postoperative day #5 the patient remained afebrile heartrate 65 and sinus blood pressure 106/60 satting at 95% onroom air. Chest tubes were discontinued. Urine output 1700.Physical exam was benign. White count 10.9 hematocrit 31.5platelet count 337000 potassium 3.9 BUN 14 creatinine .5with a glucose of 141 magnesium 2.1.Postoperative day #6 on Ceftriaxone and Clindamycin overnightevents include
atrial fibrillation
DISEASE
and heparinization forpossible PE and a chest CT scan. Patient on Amio andHeparin afebrile heart rate 108 and
atrial fibrillation
DISEASE
blood pressure 96/68 satting at 97% on three liters.Hematocrit 37 PTT 28.4 potassium 4.2. Physical exam lungswere irregularly irregular otherwise unremarkable.Postoperative day #7 the patient remained afebrile heartrate 56 blood pressure 109/65 satting at 97% on two liters.On Lopressor Lasix Ceftriaxone Clindamycin and AmiodaronePTT of 28. Physical exam unremarkable. The day prior thepatient underwent a spiral CT of the chest to rule out a PE.There was radiographic evidence for peripheral pulmonaryemboli in the left lung patient on Heparin. ID again cameby to see the patient at which time they stated that thepatient was clinically stable from an ID perspective and tocontinue the antibiotic regimen for a total of 14 days. Ifthe patient spikes a
fever
DISEASE
they were to be consulted again.Postoperative day #8 the patient remained afebrile vitalsigns stable blood pressure 116/74 satting at 99% on 4liters. Exam was benign. Plan was to check the PTT.Patient is still on Heparin.Postoperative day #9 the patient remained afebrile with aheart rate of 63 and sinus rhythm respirations 18 sattingat 96% on 3 liters blood pressure 122/70. The patient wason Heparin Lopressor Amiodarone Clindamycin Ceftriaxoneand Coumadin. On physical exam exam was benign. Plan wasto check the INR PTT and to continue aggressive pulmonaryPT. Postoperative day #9 overnight events include atrial
fibrillation
DISEASE
times one and an unchanged
cough
DISEASE
. The patientremained afebrile with heart rate of 55 and
sinus brady
DISEASE
respirations 20 satting at 95% on three liters bloodpressure 139/88 white count 9.7 hematocrit 33 plateletcount 490000 potassium 4.6 BUN 8 creatinine .6 andglucose 115. Patient on Heparin Coumadin LopressorAmiodarone Lidocaine Xanax. Exam still remained unchanged.Postoperative day #10 overnight events included atrial
fibrillation
DISEASE
and a
cough
DISEASE
which is improving. The patient wasafebrile heart rate 63 respirations 22 satting at 90% onthree liters with a blood pressure of 149/78 hematocrit34.6 BUN 8 creatinine .6 PT 16.5 PTT 83.5 with INR 1.8.Patient on Heparin Lidocaine Coumadin Xanax Amiodarone.Exam decreased breath sounds with crackles of the chest.Continue current management.Postoperative day #11 the patient remained afebrile with aheart rate of 62 respirations 18 satting at 94% on twoliters blood pressure 96/59 white count 8.5 hematocrit 30PT 17.6 PTT 113 INR 2.1. Patient on Coumadin LopressorAmiodarone Xanax and Lidocaine. Exam remained unremarkable.Plan was to set up home VNA and chest x-ray today.Patient was discharged on [**2175-7-29**].DISCHARGE DIAGNOSIS:1. Right middle lobe abscess.DISCHARGE MEDICATIONS: The patient was stable on dischargeand was discharged home on the following medications:Percocet 1-2 tablets po q 4 hours Robitussin AC 10 cc po q 4hours Ambien 10 mg po q h.s. Glyburide 5 mg po q a.m.Amiodarone 400 mg po tid for two days then 400 mg po bid for7 days then 400 mg po q a.m. for 7 days Lopressor 12.5 mgpo bid Coumadin 2.5 mg po q h.s. and adjust to keep the INRaround 2 to 2.5. [**Known firstname 177**] [**Last Name (NamePattern4) 178**] M.D. [**MD Number(1) 179**]Dictated By:[**Doctor Last Name 182**]MEDQUIST36D: [**2175-10-11**] 11:01T: [**2175-10-12**] 12:51JOB#: [**Job Number 183**]Admission Date: [**2121-10-29**] Discharge Date: [**2121-11-10**]Date of Birth: [**2086-12-16**] Sex: FService: MEDICINE
Allergies
DISEASE
:Penicillins / Codeine / Nsaids / LevaquinAttending:[**First Name3 (LF) 2901**]Chief Complaint:
Shortness of breath
DISEASE
.Major Surgical or Invasive Procedure:Right and left heart catheterization.Endomyocardial biopsy.History of Present Illness:Mrs. [**Known lastname **] is a 34 year old woman with a history of
hypertrophic cardiomyopathy hypertension SVT
DISEASE
s/p
PEA arrest
DISEASE
x3 s/p pericardial effusion/window who was transferred to [**Hospital1 18**]from [**Hospital 1474**] Hospital for
CHF
DISEASE
exacerbation and work up for
constrictive pericarditis
DISEASE
. She reports she developed bilateral
back pain
DISEASE
with inspiration about 2 days ago that is consistentwith her prior
CHF
DISEASE
exacerbation. She also reports that shenoticed that her face and lips became cyanotic with exertion athome. Of note she reports she has a baseline variable 02requirement at home from 0-2L. She otherwise denies f/c/changein appetite CP/palp/SOB/Admission Date: [**2117-1-16**] Discharge Date: [**2117-1-25**]Date of Birth: [**2072-1-20**] Sex: MService: [**Year (4 digits) 662**]
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 562**]Chief Complaint:DOE/AMSMajor Surgical or Invasive Procedure:
PD
DISEASE
BALIntubationCVVHDCentral Line placementHistory of Present Illness:44 yo male with history of HIV (CD4 202 VL 27200 in [**5-3**])
ESRD
DISEASE
[**12-31**]
HIV nephropathy CHF
DISEASE
(EF 25%) who presents with
dyspnea
DISEASE
on exertion. Pt was very lethargic when I interviewed him due torecent ativan dose. States he has been having shortness ofbreath on and off for the last week. Denies any
chest pain
DISEASE
palpitation
DISEASE
increasing LE
edema orthopnea
DISEASE
PND. States he hasbeen doing his PD 5 times a day as directed last done at 3pm anddiasylate still in peritoneal cavity. Admits to recent crackcocaine use but could not give details. Also admits to drinking[**11-30**] pint- 1 pint liquor per day. Last drink within past 24hours. States he has had recent
fevers
DISEASE
.
Denies
DISEASE
any
nausea
DISEASE
vomiting
DISEASE
.
Positive non-bloody diarrhea
DISEASE
for several days. Wasarrousable only to
pain
DISEASE
by the time MICU resident evaluated him- he had been given 4 mg ativan IV as he was confused agitated
hypertensive
DISEASE
and tachycardic in the ED - this concerning forETOH W/D. As such MICU was called to evaluate him and he wasaccepted on MICU service.Past Medical History:- HIV Admission Date: [**2187-4-20**] Discharge Date: [**2187-4-23**]Date of Birth: [**2106-8-2**] Sex: FService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 5973**]Chief Complaint:
Shortness of breath
DISEASE
altered mental statusMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:Patient is an 80 year-old patient with history of
Sjogren
DISEASE
'ssyndrome moderate
MR
DISEASE
recent hospitalization for
sepsis
DISEASE
secondary to c. diff
colitis
DISEASE
complicated by
hypercarbic
DISEASE
respiratory failure
DISEASE
requiring intubation who is presenting from[**Hospital 100**] Rehab with worsening
dyspnea
DISEASE
for one day. Patient wasdischarged from [**Hospital1 **] yesterday ([**2187-4-19**]) following hospitalizationfor c. diff
colitis
DISEASE
. Patient had ABG at [**Hospital 100**] Rehab which was7.4/73/63. Her vitals on transfer were 97.9 99 24 113/68 92%2L. She reports
shortness of breath
DISEASE
associated with the
cough
DISEASE
.She denies
chest pain
DISEASE
. She denies
nausea
DISEASE
or
vomiting
DISEASE
. She denies
abdominal pain
DISEASE
.In the ED initial vitals are 100.2 95 99/47 28 100% 4L nc.Exam was notable for
tachypnea
DISEASE
with respiratory rates in the30s. While in ED blood pressure dipped to 80s but improved onit's own. Given the
tachypnea cough
DISEASE
and
dyspnea
DISEASE
there wasconcern for
pneumonia
DISEASE
. Patient received vancomycin andlevofloxacin. CXR appeared improved from most recent CXR.Patiwnt was started on BIPAP. Patient underwent CTA to evaluatefor PE prior to leaving ED. On transfer vitals are HR 93 BP109/45 O2 sat 100% on BIPAP.On arrival to the MICU patient is wearing BiPAP but wants itremoved and does not want any other supplemental oxygen. Shedenies
pain
DISEASE
. She denies
cough
DISEASE
or
shortness of breath
DISEASE
.Review of systems:Unable to obtain patient wearing BiPAP and is delerious.Past Medical History:
Anemia
DISEASE
Borderline cholesterolC. DiffFlatulenceHealth MaintenanceHeart Murmur
Hypertension
DISEASE
Hypothyroidism
DISEASE
Mitral Regurgitation
Osteoporosis
DISEASE
Pneumonia
DISEASE
Sinusitis
DISEASE
Sjogren
DISEASE
Social History:Patient previously lived alone in an apartment and cares forherself. Currently living at rehab after recent discharge. Shedoes not use tobacco or alcohol.Family History:Long history of
hypertension
DISEASE
in her family. She does reportthat her father's family has a history of multiple
cancers
DISEASE
. Shehas a grandfather with a history of
stomach cancer
DISEASE
and an unclewith a history of
throat cancer
DISEASE
. She denies any history of
colon cancers
DISEASE
. Father had
stroke
DISEASE
. No family h/o MI. Mother had aheart valve replaced (pt not sure which one).Physical Exam:Exam upon admission:General: Awake interactive but delerious. Not oriented toplace or time calling out trying to get out of bed. Cacheticfrail elderly female.HEENT: Sclera anicteric dry mucus membranes.Neck: supple JVP not elevated no LADCV: Regular rate and rhythm normal S1 Admission Date: [**2187-5-1**] Discharge Date: [**2187-5-12**]Date of Birth: [**2106-8-2**] Sex: FService: MEDICINE
Allergies
DISEASE
:meropenemAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:Hypercarbic
Respiratory Failure
DISEASE
Major Surgical or Invasive Procedure:Mechanical Intubation Arterial -Line Central Venous AccessLineHistory of Present Illness:This is an 80 year old woman recently hospitalized for C.
Difficile sepsis
DISEASE
and
shock
DISEASE
complicated by readmissionhypoxia/hypercarbia ([**Date range (1) 5975**]) who presents with respiratorydistress and
respiratory failure
DISEASE
..The patient had reportedly been doing well in rehab until todaywhen she was noted to have an altered (
depressed
DISEASE
) mental status
tachypnea
DISEASE
and
dyspnea
DISEASE
. EMS was called who found the patient inextremis intubation was attempted x2 and failed. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] airwaywas placed and the patient was transported to [**Hospital1 18**] emergencydepartment. There were no reports of increased coughing orstooling from [**Hospital 100**] Rehab..The patient has had a complicated medical course in the pastmonth -.In brief the patient was initially discharge on [**4-19**] aftera 14 hosptilazation for c.diff colitis complicated by
sepsis
DISEASE
and
hypercarbic respiratory failure
DISEASE
requiring intubation. On theday following discharge from that admission the patient wasnoted to be complaining of worsening SOB and ABG at [**Hospital 100**] rehabwas 7.4/73/63. She was re-admitted to [**Hospital1 18**] on [**4-20**] to the MICUand intially reuqired biPAP for HD1-2. Her oxygen requirement ond/c was 2L NC. The etiology of her hypercarbic respiratory
failure
DISEASE
was felt to be [**12-21**]
hypoventilation
DISEASE
from
somnolence
DISEASE
related to oversedation with zyprexa which was held ondischarge. A CTA chest was negative for PE and showed no clearevidence of
pneumonia
DISEASE
. She was initially started on
HCAP
DISEASE
antibiotics with vanc/cefepime which were stopped on HD 4 priorto discharge given that all cultures were negative and there wasno consolidation on imaging..In the ED initial VS were: HR: 82 BP: 94 systolic Resp: Nospontaneous respirations O(2)Sat: 100Admission Date: [**2180-4-16**] Discharge Date: [**2180-4-20**]Date of Birth: [**2149-1-31**] Sex: MService: MEDCHIEF COMPLAINT: Abdominal pain.This is a 31-year-old gentleman with longstanding history of
Crohn's disease
DISEASE
since age 12 years status post ileoresection and ileocolic anastomosis. The patient wasrecently admitted in [**2179-12-16**] for a
Crohn's
DISEASE
flare and hasbeen on the steroid taper since his discharge. One weekprior to admission his prednisone was decreased from 20 mgto 10 mg and on the day prior to admission the patientdeveloped mild discomfort in his abdomen then extreme
pain
DISEASE
with
nausea
DISEASE
and
vomiting
DISEASE
today. The patient denied any
diarrhea
DISEASE
or bright red blood per rectum. His last bowelmovement was this morning. The
pain
DISEASE
is located in theperiumbilical area radiating diffusely. Of note the patienthas a new
rash
DISEASE
that started in his ears as mild
pruritus
DISEASE
. Henoted what was thought to be
pimples
DISEASE
that exposed to mildfluid initially in his ear. The
rash
DISEASE
has not progressed tohis neck back and chest. The patient has had recent travelto [**Country 5976**] but is not fully coming about the details of histrip.Of note the patient was given morphine in the ED for
pain
DISEASE
control and developed
urinary retention
DISEASE
.PAST MEDICAL HISTORY:
Crohn's disease
DISEASE
times 12 years. Thepatient has had immunosuppression with 6-MP and has also beenrecently on the steroid taper.Ileal resection with ileocolic anastomosis and small bowel
stricture
DISEASE
.Iron deficiency
anemia
DISEASE
.
Lactose intolerance
DISEASE
.Status post appendectomy.Colonoscopy in [**2179-2-13**].Prior cryptococcal
infection
DISEASE
involving spleen.ALLERGIES: No known
drug allergies
DISEASE
.CURRENT MEDICATIONS:1. Prednisone 10 mg q.d.2. Protonix 40 mg q.d.3. 6-MP 100 mg q.h.s.4. Methenamine 250 mg four capsules q.i.d.5. Entocort 9 mg p.o. q.d.6. Imodium one capsule t.i.d.SOCIAL HISTORY: Smokes half pack per day. He has been asmoker since [**20**] years. The patient drinks one to two beersper day.PHYSICAL EXAMINATION: On admission vital signs temperature97.0 heart rate 80 and blood pressure 135/75. Generallythe patient was uncomfortable appearing but in no acutedistress. HEENT: Moist mucous membranes. Oropharynx isclear. Pupils equal round reactive to light. Extraocularmovements are intact. Neck was supple without
lymphadenopathy
DISEASE
. Cardiovascular: Regular rate. S1 and S2.No murmurs rubs or gallops. Pulmonary: Clear toauscultation bilaterally. Abdomen: Normal bowel soundssoft mild
pain
DISEASE
on palpation in the periumbilical region. Nosignificant distention. No rebound or guarding.Extremities: No
clubbing cyanosis
DISEASE
or
edema
DISEASE
. Two pluspulses bilaterally. Neurologically: Alert and orientedtimes 3. Skin exam shows 2-3 mm papules over neck back andchest. Mildly
pruritic
DISEASE
and nontender.LABORATORY DATA: Labs on admission white blood count was5.4 with 86 neutrophils 11 bands and 1 plasma cell.Hematocrit was 40.1 and platelets are 246. chemistry sodium141 potassium 4.3 chloride 105 bicarb 26 bun 8creatinine 0.7 and glucose 109. ALT is 150 AST 90alkaline phosphatase 58 LDH 328 total bilirubin is 1.1lipase 20 and amylase 63. UA was negative. CT of theabdomen and pelvis showed prominence of small bowel with mild
thickening
DISEASE
and a very few short segments. Less extensive
thickening
DISEASE
than in [**2179-12-16**]. No evidence of
obstruction
DISEASE
.HOSPITAL COURSE: This is a 31-year-old male with abdominal
pain
DISEASE
initially thought to be a
Crohn's
DISEASE
flare. However overthe next 24 hours after admission the patient developed
hypoxia
DISEASE
and
respiratory distress
DISEASE
as well as worsening
abdominal pain
DISEASE
. On the following day after admission againclinical course was declining. The patient was seen by the
infectious disease GI
DISEASE
and hematology oncology consultants.That night the patient did develop the
transaminitis
DISEASE
with ALTto 674 and AST 754 with an LDH of 861 and total bilirubin1.6 pt 13.1 PTT 29.2 and INR of 1.1. D-dimer was found tobe greater than 10 000. At this time the
transaminitis
DISEASE
inthe setting of the
rash
DISEASE
was concerning for a viral etiology.Hep serologies were checked in addition to CMV EBV and an
acute HIV infection
DISEASE
. Other serologies such as
toxoplasmosis cryptococcus
DISEASE
VDV and HSV were alsoconsidered. There is a thought that the patient's
immunocompromised
DISEASE
status under section PN steroid use mightmake him more susceptible to had seminate with
zoster
DISEASE
. Againthat night the patient was started on vancomycin forpossible
skin infection
DISEASE
and doxycycline for question of tickborne diseases. on Cipro and Flagyl for a possible
Crohn's
DISEASE
flare on acyclovir for possible
seminated zoster
DISEASE
and onamphotericin for a possible
histo
DISEASE
. Dermatology acutely sawthe patient on the night of [**2180-4-17**] and noted amicropapular blenching
rash
DISEASE
which was thought to be a viralexanthem. TSA was performed showing evidence of
varicella
DISEASE
zoster
DISEASE
virus. Of note medical team was informed that thepatient had never had
chickenpox
DISEASE
and this is a primarydisseminated
varicella infection
DISEASE
. The hematology consultobtained on the night of [**2180-4-17**] was on the setting of
thrombocytopenia
DISEASE
there was some concern for symptoms ofprocess such as a
cord splenomegaly
DISEASE
or destruction by animmune mediated system such as a
viral infection
DISEASE
. Diagnosissuch as GIC HUS-TPP were considered. Coagulations hadcurrently been stable. A smear was reviewed and showed noevidence of cystocytes and
hypertension
DISEASE
was elevated. Therewas again some concern for DIC and the patient's plateletscoagulations LDH and fibrinogen were followed closely.Again that night the patient significantly decompensated andhad evidence of
respiratory distress
DISEASE
. The patient wastransferred to MICU on the night of [**2180-4-17**].Overnight in the MICU the patient remained relativelystable. However he again have evidence of hyper and
hypothermia
DISEASE
. The patient's respiratory status remainedstable. However the patient began to require increasinglevels of oxygen. The patient's O2 saturation wasapproximately 90 percent on a 10 liter V-stent. In additionthe patient was noted to be tachycardic with heart rate inthe 140s. On [**2180-4-18**] which is hospital day 3 but MICUday 1 the patient was noted to have significant abnormalityin his labs. ALT increased to 35.73 AST increased 53.23alkaline phosphatase just 180 and total bilirubin increasedto 5.8. There is evidence of mild
renal failure
DISEASE
. Plateletsdeclined to 23 haptoglobin was less than 20 and fibrinogenwas 94.At this point
hepatitis
DISEASE
serologies returned negativecryptococcal antigen was negative RPR was non-reactive CMCwas negative toxo was negative Histoplasma capsulatumantigen was negative DFA for
HSV
DISEASE
was negative. However DFAfor
VZV
DISEASE
became positive and IgG for
VZV
DISEASE
was negativeconsistent with primary
varicella infection
DISEASE
. At this pointthe patient's antibiotics were readjusted. The patient wasgiven high doses of acyclovir. Other antibiotics werediscontinued. In addition secondary to respiratorydistress the patient was intubated for worsening
hypoxia
DISEASE
.After intubation the patient became
hypotensive
DISEASE
and receivedaggressive fluid resuscitation with 12 liters fluidinitially normal saline and subsequently lactate ringers.The patient was started on Levophed for
hypotension
DISEASE
anddespite full it does not remained around 55. The patientsubsequently became difficult to oxygenate and ventilatorsettings were adjusted to maintain pao2 in 70s to 80s.The patient's pulmonary status on hospital day 4 the patientwas significantly difficult to oxygenate. Paralytics wereused to help ease the work of breathing. The patient's chestfilms and pao2 to fio2 ratio were consistent with ARDS. Thepatient was proned to assist with improvements on oxygenationand this initially helped. However the patient becamehypoxic again and was reproned. Regarding the patient's
liver failure
DISEASE
LFTS continued to rise chlorides continued torise and
renal failure
DISEASE
worsened. The patient did have someevidence of
DIC
DISEASE
and was transfused cryo for fibrinogen lessthan 100. The patient was continued to be treated withacyclovir. However given repeated
fevers
DISEASE
the patient wasalso started on cefepime and on vancomycin. Regarding his
renal failure
DISEASE
and multiple issues the patient's
acidosis
DISEASE
wasthought to be to secondary to
shock
DISEASE
versus tissue
necrosis
DISEASE
versus
renal failure
DISEASE
versus electrolyte abnormalities. Thevent was adjusted to compensate for pH. The patient wasgiven large doses of bicarbonates to adjust his
acidosis
DISEASE
.ABG at that time was 7.14 38 and 86.Regarding his
acute renal failure
DISEASE
the patient's bun andcreatinine continued to rise despite fluids. There was somethought about initiating CVVH and ultimately a catheter wasplaced by the renal team. On the hospital day next thepatient was significantly hypoxic with pao2 in 37 withincreasing difficulty to oxygenate. Prior to this time thepatient had been ruled in an esophageal balloon study to helpdetermine adequate peak. The patient secondary to ventilatorprotective strategies under the Argonaut protocol thepatient had been receiving higher doses of PEEP to improveoxygenation. However on this day the patient developedevidence of
pneumomediastinum
DISEASE
. The patient was proned withslight improvements in his po2.Other issues the patient's
acidosis
DISEASE
continued to worsen.His
hypotension
DISEASE
however improved with the patient remainedpressor dependent. Further imaging was performed in order tounderstand etiology of
liver failure
DISEASE
. Ultrasound showedclots in the portal vein decreased splenic vein flow patenthepatic veins and IVC. The patient was started on low-doseheparin. There is some concern that there is evidence ofhypercoagulable state. Again at this time the patientremains intubated on four pressors with increasing difficultyoxygenating. The patient's transaminases continued to riseas well as
coagulopathy
DISEASE
worsening and
renal failure
DISEASE
worsening. A lactate measured on this day was 26. Regardinghis problem his
hypoxia
DISEASE
and
respiratory failure
DISEASE
was thoughtto be due to
varicella pneumonitis
DISEASE
. The patient is on theventilator with Argonaut protocol in the setting of
pneumomediastinum
DISEASE
and there was concern for
pneumothorax
DISEASE
.At this point it was thought to put him prophylactic chesttubes in the setting of the patient was to develop a
pneumothorax
DISEASE
. However the patient's clinical statusdeclined secondary to
multisystem organ failure
DISEASE
before thiscould be initiated.The running of
hypotension
DISEASE
and shockAdmission Date: [**2138-1-6**] Discharge Date: [**2138-1-14**]Date of Birth: [**2074-6-8**] Sex: FService: MEDICINE
Allergies
DISEASE
:TricorAttending:[**First Name3 (LF) 898**]Chief Complaint:
pneumonia
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:63F with type 2
diabetes coronary artery disease
DISEASE
s/p CABGpresents with 2 days history of productive
cough shortness
DISEASE
ofbreath fever/chills and L-sided pleuritic
chest pain
DISEASE
. Chest CTrevealed dense multi-lobular L PNA. Patient was intubated in EDbecause of increasing respiratory effort. Approximately 30minsafter intubation she became
hypotensive
DISEASE
with mean arterialpressure in high 50s requiring levophed. Sepsis protocol wasinitiated & patient was given empiric ceftriaxone Azithromycinand Vancomycin. Initial labs were notable for a WBC of 7.6 with18% bands INR 1.8 Mg 1.1 fibrinogen 700 lactate 5.1 trendingdown to 2.3 after 4L NS. EKG was without acute changes and CE x1 negative. Sputum GS revealed 4Admission Date: [**2189-9-30**] Discharge Date: [**2189-10-2**]Date of Birth: [**2127-4-7**] Sex: MService: [**Hospital Unit Name 196**]
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2704**]Chief Complaint:ELECTIVE CAROTID ANGIOGRAPHY AND LEFT INTERNAL CAROTID STENTINGMajor Surgical or Invasive Procedure:Bilateral Carotid Angiography and Left Internal Carotid StentingHistory of Present Illness:Pt is a 62 y.o man w/ h/o CAD s/p Admission Date: [**2189-12-26**] Discharge Date: [**2190-1-6**]Date of Birth: [**2127-4-7**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2698**]Chief Complaint:
chest pain shortness of breath
DISEASE
Major Surgical or Invasive Procedure:
cardiac cath s/p stent to left main LAD
DISEASE
IABP placementHistory of Present Illness:62 yr old male with
3VD CHF
DISEASE
20-25% with 3-4Admission Date: [**2145-11-8**] Discharge Date: [**2145-12-6**]Date of Birth: [**2084-11-22**] Sex: FService: NEUROLOGY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4583**]Chief Complaint:[**Last Name (un) 4584**] [**Location (un) **] SyndromeMajor Surgical or Invasive Procedure:5-days IVIG therapyHistory of Present Illness:The patient is a 60-year-old left-handed woman with a history of
chronic inflammatory demyelinating polyneuropathy
DISEASE
(
CIDP
DISEASE
) fromwhich she recovered fully about 20 years ago who presents froman outside hospital today with 2 days of
paresthesias
DISEASE
and one day of
weakness
DISEASE
for evaluation of possible[**Last Name (un) 4584**] [**Location (un) **] Syndrome. The patient reports that on [**10-28**] sheunderwent a t-lith procedure and initially had made an excellentrecovery. However 2 days prior to presentation she noted thatshe had tingling of the hands and feet with an abnormaldecreased sensation over the remainder of her upper and lowerextremities as though it were Admission Date: [**2109-3-19**] Discharge Date: [**2109-3-21**]Date of Birth: [**2022-7-8**] Sex: FService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 4309**]Chief Complaint:
Hyperglycemia
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:Ms. [**Known lastname 4587**] is an 86 year old female with multiple medicalproblems including bilateral
unprovoked PE
DISEASE
's on coumadin CAD
diabetes
DISEASE
on home insulin complicated by LE
ulcers
DISEASE
who wasinitially referreed into the ER by her VNA for
hyperglycemia
DISEASE
.She has been being seen every other day by a VNA for wound careof her lower extremity
ulcers
DISEASE
which per her report have beenimproving and this morning she was noted to have a blood sugarof 411. She says that she took her usual insulin regimen thismorning which is 6units of NPH and 20 units of regular.Additionally she completed an empiric 10 day course ofciprofloxacin 4 days ago which was prescribed by her podiatristfor her lower extremity
ulcers
DISEASE
however the
dysuria
DISEASE
she had beenhaving improved but did not resolve. She says that at baselineshe is incontinent she continues to have
dysuria
DISEASE
but thinksthat her urine output has actually decreased recently. Shethinks that her LE
ulcers
DISEASE
have been improving she denies anyassociated fever/chills n/v/d
abdominal pain
DISEASE
leg
pain
DISEASE
chest
pain
DISEASE
or
shortness of breath
DISEASE
.In the ED initial VS were: 99.4 57 110/44 16 100% on
RA
DISEASE
.She was initially alert and interactive but about 30min latershe was found to be much less interactive and her labs returnedwith a blood sugar of 39 she was then given 1 amp of D50 withimprovement in her mental status and repeat FS was 238. At thetime of her
hypoglycemia
DISEASE
she was also noted to feel cool to thetouch at which time a rectal temperature was done that was 35degress celsius. Other than the
hypoglycemia
DISEASE
her labs werenotable for a Cr of 2.9 from a baseline of 1.1-1.6 her INR was6.0 lactate of 1.4 white count was 7.9 no bands but 1 metaand 1 myelo U/A with 135 WBC's many bacteria trace blood and30 protein. X-rays of her LLE did not show any evidnece of
osteomyelitis
DISEASE
and CXR did not show any evidence of
pnuemonia
DISEASE
.Additionally in the ER she had an episode of
hypotension
DISEASE
to78/35 which improved to SBP's in the 110's after 2LNS. She wasgiven ceftriaxone for the
UTI
DISEASE
and vancomycin for possible
cellulitis
DISEASE
surrounding her LE
ulcers
DISEASE
. VS on transfer: rectaltemp of 34.3C 55 111/63 17 95% on
RA
DISEASE
..On arrival to the MICU her initial VS were: 93.9 69 110/6316 92% on
RA
DISEASE
. She currently is denying any
pain
DISEASE
her only
complaint
DISEASE
is that she continues to feel cold. She also saysthat she has a
chronic cough
DISEASE
that is unchanged.Past Medical History:1. Bilateral
pulmonary embolism
DISEASE
of unknown etiology onCoumadin.2. Recent history of
osteomyelitis
DISEASE
now treatment completed.3.
Diabetes mellitus
DISEASE
type 2.4. Coronary
artery disease
DISEASE
.5.
Hypertension
DISEASE
.6. Hypercholesteremia.7.
Hyperthyroidism
DISEASE
.8. Depression.Social History:The patient lives with her husband in [**Name (NI) 1468**]and manages her activities of daily living as well asinstrumental activities of daily living without any problems.Shehas five sons all of whom live close by.Family History:The patient's mother died in her early 80s with
Alzheimer's
DISEASE
disease. Her father had
tuberculosis
DISEASE
. No other significantfamily history.Physical Exam:General: Alert oriented no acute distressHEENT: Sclera anicteric MMM oropharynx clear EOMI PERRLNeck: supple JVP not elevated no LADCV: Regular rate and rhythm normal S1 Admission Date: [**2175-9-18**] Discharge Date: [**2175-9-28**]Date of Birth: [**2114-2-8**] Sex: MService: CCU/MEDICAL ICU/C-MEDICINEHISTORY OF PRESENT ILLNESS: The patient is a 61 year old manwith a history of stage III
squamous lung carcinoma
DISEASE
statuspost lobectomy and pneumonectomy on the right earlier thisyear who was transferred to [**Hospital1 188**] for
respiratory failure
DISEASE
. Two weeks prior toadmission the patient began experiencing episodes of
shortness of breath cough
DISEASE
and
dyspnea
DISEASE
. Echocardiogram andelectrocardiogram performed at that time were reportedlyunremarkable.On [**2175-9-17**] after coming home from his son's wedding thepatient became acutely short of breath agitated andcollapsed on the floor stating that he could not breathe.His family called 911 and the patient was intubated in thefield and taken to [**Hospital 189**] Hospital where a chest x-ray wasreportedly normal but electrocardiogram showed transient newleft
bundle branch block
DISEASE
ST elevations in leads II throughV4 and Q waves in the anterior precordial leads all of whichwas new. He was transferred to the [**Hospital1 190**] and Coronary Care Unit for further evaluationand management.PAST MEDICAL HISTORY:1. Stage III-A
squamous cell lung carcinoma
DISEASE
status postright pneumonectomy chemotherapy and radiation.2. Transient ischemic attack.3.
Pulmonary embolism
DISEASE
.4.
Atrial fibrillation
DISEASE
on Amiodarone.5. Prostate cancer status post radical prostatectomy.6.
Diabetes mellitus
DISEASE
.7. Negative exercise Thallium test in [**2175-2-26**].ALLERGIES: The patient has no known drug
allergies
DISEASE
.MEDICATIONS ON ADMISSION:1. Amiodarone 400 mg p.o. b.i.d.2. Coumadin 3 mg p.o. q.h.s.3. Oxazepam p.r.n.4. Lopressor 12.5 mg p.o. b.i.d.5. Glyburide 5 mg p.o. q.d.6. Neurontin 100 mg p.o. t.i.d.7. Ambien 10 mg p.o. q.h.s.FAMILY HISTORY: The patient has a sister who died of
cancer
DISEASE
at the age of 39 and an older brother status post coronaryartery bypass graft. His father also had coronary arterydisease and a sister has
cardiac valve disease
DISEASE
.SOCIAL HISTORY: The patient quit smoking three months agofollowing three to four packs per day times forty years. Heconsumed two to three drinks per day. He is a constructionworker.PHYSICAL EXAMINATION: On admission temperature is 99 heartrate 70 to 80s blood pressure 110/60 oxygen saturation 95%.In general the patient was intubated and sedated. Headeyes ears nose and throat examination indicated the pupils2.0 millimeters and reactive bilaterally. Endotracheal tubeis in place.
Cardiovascular - tachycardia
DISEASE
with no murmursrubs or gallops. Pulmonary examination - The patient haddiffuse
coarse rhonchi
DISEASE
on the left and absent breath soundson the right. The abdomen was soft nontender nondistendedwith
normal bowel sounds
DISEASE
. The extremities were warm with 1Admission Date: [**2109-10-16**] Discharge Date: [**2109-10-18**]Date of Birth: [**2022-7-8**] Sex: FService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:AMSMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:87 yo F with
T2DM c/b peripheral neuropathy
DISEASE
CAD s/p stentchronic
anemia HTN
DISEASE
h/o PE on warfarin and other medical issuespresents from home with AMS.Touched base with patient's PCP who states that patient has notbeen doing well with slow decline and hospice option has beenentertained recently. She is supposed to have hospice nursevisiting for initial evaluation on Monday. Patient has beennoted to be
depressed
DISEASE
but mentating well at baseline.Per patient's husband patient has not been eating well ordrinking well for the last few weeks. Her mental statusdeclined significantly over the last week. She has complainedabout suprapubic
pain
DISEASE
for the last few days. She had VNA onMondayPer EMS patient is arousable with verbal stimuli FSBS 311.Patient appeared dry cool to touch.In the ED inital VS were 97.8 72 148/104 22. Per report Admission Date: [**2108-3-20**] Discharge Date: [**2108-3-23**]Date of Birth: [**2043-7-15**] Sex: MService: MEDICINE
Allergies
DISEASE
:lisinoprilAttending:[**First Name3 (LF) 4358**]Chief Complaint:
fever
DISEASE
at dialysisMajor Surgical or Invasive Procedure:HemodialysisHistory of Present Illness:64M w/ h/o
schizoaffective disorder
DISEASE
&
ESRD
DISEASE
[**3-1**] lithium toxicityadmitted from [**Location (un) **] [**Location (un) **] for
fever
DISEASE
at
HD
DISEASE
in ED febrile to104F w/tachycardia to 130s (sinus) admitted to ICU for possible
septic shock
DISEASE
source still unclear. CXR clear. UA clean. NolineAdmission Date: [**2172-3-9**] Discharge Date: [**2172-3-14**]Service: MEDICINE
Allergies
DISEASE
:Morphine SulfateAttending:[**First Name3 (LF) 443**]Chief Complaint:HypoxiaMajor Surgical or Invasive Procedure:1. Intubation2. Right Radial Arterial LineHistory of Present Illness:This is an 87-year-old woman with an extensive PMH including CAD3 vessel
HTN CHF
DISEASE
mod-severe AS who presented with acuterespiratory distress requiring intubation. Ms. [**Known lastname 4602**]developed increasing
dyspnea
DISEASE
at home since yesterday withelevated blood pressure last evening (SBP Admission Date: [**2173-8-14**] Discharge Date: [**2173-8-26**]Service: MEDICINE
Allergies
DISEASE
:Morphine SulfateAttending:[**First Name3 (LF) 1253**]Chief Complaint:AMS
shortness of breath
DISEASE
Major Surgical or Invasive Procedure:PICC lineHistory of Present Illness:88yo F PMhx
CHF HTN
DISEASE
presenting w AMS in the setting of a fall.1d prior to presentation patient was getting out of bathtubwhen she slippedAdmission Date: [**2117-4-15**] Discharge Date: [**2117-4-21**]Date of Birth: [**2054-11-28**] Sex: MService: CCUCHIEF COMPLAINT: Shortness of breath.HISTORY OF PRESENT ILLNESS: The patient is a 62 year oldmale with
HIV and coronary
DISEASE
risk factors including
diabetes
DISEASE
mellitus hyperlipidemia
DISEASE
family history of coronary arterydisease and male sex who presented to his primary carephysician with two months of progressive
dyspnea
DISEASE
on exertion.The patient had cardiac echocardiogram which showed ejectionfraction of 20% and 3Admission Date: [**2121-8-3**] Discharge Date: [**2121-8-6**]Date of Birth: [**2040-10-31**] Sex: FService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 603**]Chief Complaint:FallMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:80F Russian-speaking with hx of afib on coumadin HTN lung cas/p left pneumonectomy with recent fall and L humerus fx 3Dago presents after fall Admission Date: [**2165-12-25**] Discharge Date: [**2166-1-8**]Date of Birth: [**2084-3-20**] Sex: FService: MEDICINE
Allergies
DISEASE
:CodeineAttending:[**First Name3 (LF) 4611**]Chief Complaint:chest pressureMajor Surgical or Invasive Procedure:Cardiac cathetherizationHistory of Present Illness:[**Known firstname 2127**] [**Known lastname 4612**] is a 81 yo female with a past medical history ofCAD with a 1 vessel CABG (SVG to LAD) in [**2134**] who presents withchest pressure. She woke up at 8 am with substernal chestpressure. It was severe initially. She took SL NTG x3 withrelief of CP for a short period of time. The CP radiated to herright side and eventually down both arms. She reports
diaphoresis
DISEASE
but denied associated
nausea vomiting
DISEASE
lightheadedness or dizziness. She reports that she has feltmildly SOB since her recent
pneumonia
DISEASE
(first diagnosed appox [**6-24**]weeks ago). She denied worsening
dyspnea
DISEASE
. Her
cough
DISEASE
hasimproved substantially and is very minimal at this time. Shewent to her PCP's office and was found to have a new
LBBB
DISEASE
andanterior ST elevations. She was transferred to the ED. Shereceived Plavix 300mg Aspirin boluses of heparin andintegrillin. Code STEMI was called and went to the cath lab.Cath showed occluded SVG Native 3vd occluded proximal LAD.Wiring the LAD was difficult and there was concern about apossible dissection. One BMS was placed in the proximal LAD.Distal
LAD
DISEASE
is diminutive past 1st septal and diag branches.She has been hemodynamically stable with HR 60-70s and SBP120-130s. On the floor she is currently
chest pain
DISEASE
free andfeels well...On review of systems she denies any prior history of deep
venous thrombosis pulmonary embolism bleeding
DISEASE
at the time ofsurgery
myalgias joint pains cough hemoptysis
DISEASE
black stoolsor red stools. She denies recent
fevers chills
DISEASE
or
rigors
DISEASE
. Allof the other review of systems were negative..Cardiac review of systems is notable for absence of
chest pain
DISEASE
dyspnea
DISEASE
on
exertion paroxysmal nocturnal dyspnea orthopnea
DISEASE
ankle
edema palpitations syncope
DISEASE
or
presyncope
DISEASE
.Past Medical History:1. CARDIAC RISK FACTORS: -
Diabetes
DISEASE
Admission Date: [**2167-2-13**] Discharge Date: [**2167-2-19**]Date of Birth: [**2084-3-20**] Sex: FService: MEDICINE
Allergies
DISEASE
:CodeineAttending:[**First Name3 (LF) 613**]Chief Complaint:Difficulty in breathingMajor Surgical or Invasive Procedure:noneHistory of Present Illness:The patient is a 82 year-old female with a history of
NSCLC
DISEASE
(stage IV) who presents with
shortness of breath
DISEASE
..The patient was in her usual state of health until the eveningbefore admission when she began to feel somewhat short ofbreath. The next morning this sensation persisted so shebecame concerned. She also reports a few day history of anon-productive
cough
DISEASE
. Denies sick contacts recent travel orsedentary lifestyle. She denied
chest pain fever chills
DISEASE
dizziness lightheadedness
DISEASE
or
syncope
DISEASE
. She presented to the EDwhere she was found to be hypoxic to the 70s on room air..In the ED she was placed on a non-rebreather with sats up tothe high 90's. Attempts were made to wean her to NC but theywere unsuccessful as she was satting 88% on 4L NC. Sheremained afebrile in the ED but was found to have WBC of 17.Given that she received levofloxacin and vancomycin. Bloodcultures were drawn prior to antibiotic administration. CXR didnot show PNA but demonstrated progression of known
lung cancer
DISEASE
. She underwent a CT head to rule out metastases which wasnegative. On transfer patient was afebrile with HR- 77 BP-112/49 RR- 16 SaO2- 98% on 15L NRB.On transfer to the ICU the patient was stable and comfortable.Sats were 97% on 5L NC and 95% high-flow with a face-tent..ROS: The patient denies any
fevers chills
DISEASE
weight change
nausea vomiting abdominal pain diarrhea constipation
DISEASE
melena hematochezia chest pain orthopnea
DISEASE
PND lowerextremity
edema cough
DISEASE
urinary frequency urgency dysuria
lightheadedness gait unsteadiness focal weakness vision
DISEASE
changes
headache rash
DISEASE
or skin changes..Past Medical History:CAD s/p MI [**2134**] s/p CABG [**2165**]
Hypertension
DISEASE
Dyslipidemia
DISEASE
CVA
DISEASE
: small left posterior frontal
infarct
DISEASE
in [**12/2164**]Macular DegenerationNSCLC- stage IV (oncology history below).-- [**12/2165**] presented in with unresolving right-sided pulmonaryinfiltrate and an unrelated
myocardial infarction
DISEASE
.-- [**2166-1-2**] Sputumcytology confirmed
adenocarcinoma
DISEASE
with apattern of stainpositivity consistent with lung origin (CK7 andTTF-1 positive). She had stage IV
nonsmall cell lung cancer
DISEASE
based on the multiple intrapulmonary lesions. She has noevidence of extrathoracic or central nervous system involvementwith
metastasis
DISEASE
.-- [**2166-1-7**]---Admission Date: [**2167-7-30**] Discharge Date: [**2167-7-31**]Date of Birth: [**2084-3-20**] Sex: FService: MEDICINE
Allergies
DISEASE
:CodeineAttending:[**First Name3 (LF) 3556**]Chief Complaint:
Dyspnea
DISEASE
and
melena
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Ms. [**Known lastname 4612**] is a 83yo F with history of stage IV
non-small
DISEASE
cell lung cancer CAD and
CKD
DISEASE
who presents with
dyspnea
DISEASE
productive
cough
DISEASE
and
melena
DISEASE
. Patient has had 7-8 days of
melena
DISEASE
without
abdominal pain
DISEASE
and
dyspnea
DISEASE
with worsening
cough
DISEASE
for thepast day. She denies
fevers
DISEASE
or
chest pain
DISEASE
..In the ER initial vitals were 97.2 89 156/53 22 86% 4L. Herhct was 22 from recent baseline of 25 (she has transfusiondependent
anemia
DISEASE
) and she initially was hypoxic. ABG was7.29/64/42/32 and lactate was 2.4. Patient responded to nebsstress dose steroids levaquin and ceftriaxone with improvementin her sats to mid 90s on 5L NC. She was started on IV PPI forher guaiac positive dark brown stool. CXR showed large R pleuraleffusion and questionable L lower lobe collapse. EKG showedsinus tach with ST depressions in V2-6. Vitals on transfer tothe MICU were 97.2 105 127/50 29 96% 5L NC..In the MICU she reports feeling better after her breathingtreatments today. She cannot recall when her difficultybreathing started and per her family she has difficulty hearingbut no
memory loss
DISEASE
. Patient had
intermittent dyspnea
DISEASE
for weeksfor which she previously took codeine syrup but then a period ofimprovement. She developed worsening dypsnea and
cough
DISEASE
yesterdaywithout
fevers chills
DISEASE
or
chest pain
DISEASE
. She denies prior historyof
melena
DISEASE
but has had stable
nausea
DISEASE
and poor appetite formonths. No
heartburn
DISEASE
or
dysphagia
DISEASE
.Past Medical History:Stage IV
nonsmall cell lung cancer adenocarcinoma
DISEASE
EGFRwild-type KRAS mutatedCAD s/p CABG in [**2134**] MI [**12-25**] s/p PCI to LAD.
Chronic renal insufficiency
DISEASE
- Patient with GFR Admission Date: [**2107-2-26**] Discharge Date: [**2107-2-27**]Date of Birth: [**2040-5-3**] Sex: FService: NeurosurgeryHISTORY OF PRESENT ILLNESS: This is a 66 year old female whowas in her usual state of health until lunch on [**2-26**] whenshe developed a sudden onset
headache
DISEASE
visual changes and
nausea
DISEASE
. Emergency medical services was called and thepatient was transported to [**Hospital6 4620**] forcare. The patient was oriented times one and combative atthe outside hospital and was intubated there. The patientwas then transferred to the [**Hospital6 2018**] for further management. On computerized tomographyscan the patient had a large
intracranial hemorrhage
DISEASE
in theleft parietal lobe measuring 6 cm with severemidline shift.PAST MEDICAL HISTORY: 1. HeadachesAdmission Date: [**2118-12-7**] Discharge Date: [**2118-12-9**]Date of Birth: [**2073-12-25**] Sex: FService: NEUROSURGERY
Allergies
DISEASE
:CodeineAttending:[**First Name3 (LF) 1854**]Chief Complaint:Skull defectMajor Surgical or Invasive Procedure:s/p cranioplasty on [**2118-12-7**]History of Present Illness:44 yo female with a h/o
left frontal AVM
DISEASE
in the supplementarymotor area. The
AVM
DISEASE
was treated with stereotactic radiosurgery(Gamma Knife)in [**2114**]. In [**2116**] the patient developed a
seizure
DISEASE
disorder
DISEASE
. [**2118-5-27**] she developed
headaches
DISEASE
and after an MRI and a digital angiogram showed noresidual pathological vessels a contrast enhancing lesionwith massive focal residual
edema
DISEASE
was diagnosed- verylikely represents
radionecrosis
DISEASE
. The patient had midlineshift and mass effect. On [**2118-8-10**] she had a left craniotomy forresection of the
radionecrosis
DISEASE
. She then presented to the officein [**2118-8-27**] with increased
left facial swelling
DISEASE
and incisiondrainage she was taken to the OR for a wound washout andcraniectomy. She now returns for a cranioplasty after a longcourse of outpatient IV antibiotic therapy.Past Medical History:seizuresh/o radio therapy for avm has resid
edema
DISEASE
causingseizuresAdmission Date: [**2176-7-30**] Discharge Date: [**2176-8-4**]Date of Birth: [**2114-2-8**] Sex: MService: [**Hospital1 212**]HISTORY OF PRESENT ILLNESS: The patient is a 62 year-oldmale with a past medical history of
squamous cell lung cancer
DISEASE
treated with right total pneumonectomy chronic obstructive
pulmonary disease
DISEASE
on 2 to 3 liters of home oxygen withsaturations in the low 90s at baseline congestive heart
failure
DISEASE
and
diabetes mellitus
DISEASE
type 2 who was recentlyadmitted from [**7-15**] to [**2176-7-19**] for presumed
bronchitis
DISEASE
or
bronchiectasis
DISEASE
flare here with recurrent
cough
DISEASE
shortness of breath
DISEASE
and
fevers
DISEASE
. During his last admissiontwo weeks ago he was treated for
chronic obstructive
pulmonary disease
DISEASE
flare versus
bronchitis
DISEASE
with a ten dayPrednisone taper and Augmentin for one week. He underwentbronchoscopy due to concern for possible endobronchiallesion which was normal. Sputum sample was done at thattime showed no growth. He was discharged at his baselinefunction on [**2176-7-19**]. The plan was to treat him for oneweek of Augmentin skip one week followed by Bactrim for oneweek skip one week and then on Augmentin for two weeks for
pneumonia
DISEASE
prophylaxis. The last dose of Augmentin was[**2176-7-22**] after being on Augmentin for only three days.He was doing well until approximately one week ago when hedeveloped mild
spasms
DISEASE
in the afternoon that he thought wasdue to low potassium. Within the following days hecomplained of worsening
cough
DISEASE
productive of clear sputum. Hehad a low grade temperature mild
headache
DISEASE
and worsening
cough
DISEASE
and presented to the Emergency Department. He deniedany
sinus pain sore throat chest pain abdominal pain
DISEASE
diarrhea dysuria
DISEASE
or
joint pain
DISEASE
. In the Emergency Departmenthe was febrile to 102 orally and had a heart rate of 160 anda blood pressure of 118/56. Respiratory rate 28. Sating 88to 98% on 100% nonrebreather. Initially he was stable butthen had a gradual change in mental status with
hypoxia
DISEASE
which resulted in his elective intubation. He received Lasix100 mg intravenous twice 1 mg of Bumex and 1 gram ofCeftriaxone as well as 125 mg of Solu-Medrol. He was alsoplaced on a heparin drip for a subtherapeutic INR and givenmorphine and Ativan for sedation. Chest x-ray showed nofocal
pneumonia
DISEASE
or evidence of
heart failure
DISEASE
. The patientthen underwent a CT angiogram of the chest that showed noevidence of
pulmonary embolism
DISEASE
.PAST MEDICAL HISTORY: 1. Stage three
squamous cell lung
DISEASE
cancer
DISEASE
diagnosed in [**2175-2-26**] status post rightpneumonectomy in [**2175-6-28**] treated with neoadjuvantradiation therapy and carboplatin and Taxol. 2. Chronic
obstructive pulmonary disease
DISEASE
. 3. Congestive heart failurelast echocardiogram [**2176-6-18**] with limited views showinggrossly preserved left ventricular function and rightventricular function. 4.
Atrial fibrillation
DISEASE
in thepostoperative period. 5. History of
prostate cancer
DISEASE
diagnosed in [**2172-2-26**] status post radical proctectomywith
penile
DISEASE
prosthesis in [**2172-8-27**]. 6. Diabetes
mellitus
DISEASE
type 2. 7. History of
urosepsis
DISEASE
. 8. History of
pulmonary embolus
DISEASE
postoperative in [**2175-6-28**]. 9.
Myocardial infarction
DISEASE
with a troponin of 4.1 in [**2175-6-28**]. Cardiac catheterization showed 30% right coronarylesion normal left ventricular function with an ejectionfraction of 50%. 10. Transient ischemic attack in [**2165**].11. Gout. 12.
Gastroesophageal reflux disease
DISEASE
. 13. Sleep
apnea
DISEASE
. 14. Colonic polyps discovered in [**2173-5-27**]. 15.
Hypercholesterolemia
DISEASE
. 16. Small
pericardial effusion
DISEASE
in[**2176-5-27**] which subsequently resolved.ALLERGIES: Doxepin causes
delirium
DISEASE
and Levaquin causesprolonged QTs.MEDICATIONS ON ADMISSION: Bactrim 800 mg/160 one tablettwice a day for one week skip one week and then Augmentin 500mg three times a day. Potassium 40 milliequivalents twice aday. Protonix 40 mg once daily. Lasix 160 mg b.i.d.Uniphyl 200 mg q.d. Zestril 2.5 mg q.d. Serevent two puffsb.i.d. Flovent 110 micrograms four puffs twice a day.Combivent inhaler two puffs four times a day. Duo-nebsolution four times a day as needed. Amiodarone 200 mg q.d.enteric coated aspirin 325 mg a day Glyburide 5 mg once aday Colace 100 mg twice a day Senna prn Coumadin 5 mg oncea day except for 4 mg on Tuesday and Thursday Neurontin 300mg b.i.d. Oxycontin 20 mg t.i.d. Paxil 20 mg q.d. Lipitor10 mg q.d. Ambien 15 mg q.h.s. and a regular insulin slidingscale.SOCIAL HISTORY: The patient quit smoking in [**2175-5-28**]following a forty year history of smoking three to four packsa day. He consumed two to three drinks alcoholic drinks perday and was a construction worker.FAMILY HISTORY: The patient has a sister who died of
cancer
DISEASE
at the age of 39 and an older brother who had a coronaryartery bypass graft. His father also had coronary arterydisease and he had a sister with
cardiac valvular disease
DISEASE
.PHYSICAL EXAMINATION: This was a gentleman who wasintubated sedated and responsive only to noxious stimuli.Pupils were unremarkable. There were no
bruits
DISEASE
in the neck.Heart had a regular rate and rhythm with normal S1 and S2sounds faint heart sounds overall. Occasional ectopicbeats. Lungs were clear to auscultation on the left withtransmitted breath sounds on the right. Abdomen was soft andmildly distended with
decreased bowel sounds
DISEASE
. Extremitiesshowed no evidence of
ulcers trace edema
DISEASE
in both lowerextremities and no
cyanosis
DISEASE
or
clubbing
DISEASE
. Skin showed noevidence of
rashes
DISEASE
.LABORATORY EXAMINATION: Urinalysis was unremarkable. Whiteblood cell count 23 hematocrit 42 platelets were 297.HOSPITAL COURSE: Upon admission to the hospital the patientwas transferred to the Medical Intensive Care Unit where hewas treated for presumed
bronchitis
DISEASE
versus
tracheobronchitis
DISEASE
versus atypical
pneumonia
DISEASE
. Blood sputum urine and stoolcultures were sent and Ceftriaxone and Azithromycin werestarted.1. Infectious disease: The patient did not develop a focalinfiltration throughout his hospitalization. His Ceftriaxonewas stopped and he was continued on Azithromycin. Heremained afebrile throughout the rest of his hospital stayand his white blood cell count decreased daily. On hospitalday two he was stable for extubation and tolerated extubationvery well. He was then transferred on hospital day numberthree out of the Intensive Care Unit to the medical floor.He continued to improve clinically with a decrease in his
fever
DISEASE
curve and decrease in his oxygen requirements. He alsosubjectively improved and on his last hospital day he wascomfortable and ambulating without oxygen. He stated that hehad come back to his baseline. White blood cell countreturned to [**Location 213**] range and cultures were negative exceptfor one anaerobic bottle that was growing gram positivecoxae that had been unidentified by the time of discharge.2. Pulmonary: This was treated as possible
tracheobronchitis
DISEASE
versus
chronic obstructive pulmonary
DISEASE
disease versus atypical
pneumonia
DISEASE
. The patient was kept onhis usual inhaler and nebulizing medications as well asAzithromycin and intravenous Solu-Medrol. After hospital daynumber two and the patient was extubated and improving theSolu-Medrol was switched to Prednisone and was rapidlytapered. The patient was encouraged to ambulate and wasgiven regular respiratory treatment and chest physicaltherapy. By the end of the hospitalization the patient feltthat he had returned to his baseline lung function baselinepulmonary function and was coughing up less dark sputum. Tomanage his
congestive heart failure
DISEASE
Lasix was usedjudiciously in order to gently diurese him over the course ofthe hospitalization followed by urine output and dailyweights. The patient responded to this well and felt overallthat his symptoms of
volume overload
DISEASE
had improved.3. Cardiovascular: Based on his presentation it was notclear that there was not a cardiac component causing hischange in his status so cardiac enzymes were sent. Threesets of enzymes were negative and showed no evidence of
myocardial infarction
DISEASE
. He had a number of electrocardiogramsthat were checked to ensure that he did not have asignificantly prolonged QTC interval and that it was notworse.4. Endocrine: The patient was followed with blood glucosemeasurements that showed that his glucose was under poorcontrol with the Glyburide and the regular insulin slidingscale. As the regular insulin sliding scale was increasedand the Prednisone was tapered these values returned closerto normal.CONDITION ON DISCHARGE: Improved.DISCHARGE STATUS: To home.DISCHARGE MEDICATIONS: 1. Humibid LA 600 mg b.i.d. 2.Lasix 160 mg b.i.d. 3. Potassium 40 milliequivalents pob.i.d. 4. Uniphyll 200 mg q.d. 5. Protonix 40 mg q.d. 6.Zestril 2.5 mg q.d. 7. Serevent two puffs b.i.d. 8.Flovent 110 micrograms four puffs b.i.d. 9. Combivent twopuffs q.i.d. 10. Scopolamine patch q 72 hours. 11.Albuterol nebulizer q 6 hours prn. 12. Amiodarone 200 mg poq.d. 13. Enteric coated aspirin 325 mg q.d. 14. Glyburide5 mg q.a.m. 15. Regular insulin sliding scale as perpreviously. 16. Colace 100 mg po b.i.d. 17. Senna twotabs po b.i.d. 18. Coumadin on hold until [**8-5**]. 19.Prednisone taper over eight days. 20. Augmentin 500 mgt.i.d. 21. Lipitor 10 mg q.d. 22. Neurontin 300 mg pob.i.d. 23. Oxycodone 20 mg q 8 hours prn. 24. Paxil 20 mgpo q.d. 25. Ambien 10 to 15 mg po q.h.s. prn.The patient had been using Care Group Respiratory Services athome for pulmonary physical therapy and O2 assistance and sothis was arranged on an outpatient basis with chest physicaltherapy and incentive spirometry and other pulmonarytreatments. The plan was that he would follow up with Dr.[**Last Name (STitle) **] in clinic the following week and that he would havean INR drawn on [**8-6**] calling the results to Dr. [**Last Name (STitle) **].DISCHARGE DIAGNOSES:1. Bronchitis.2. Possible atypical
pneumonia
DISEASE
. [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**] M.D. [**MD Number(1) 200**]Dictated By:[**Last Name (NamePattern1) 214**]MEDQUIST36D: [**2176-8-4**] 15:11T: [**2176-8-12**] 06:15JOB#: [**Job Number 215**]Admission Date: [**2145-6-27**] Discharge Date: [**2145-7-2**]Service: [**Location (un) 259**]HISTORY OF PRESENT ILLNESS: On admission the patient is an86[**Hospital 4622**] nursing home resident who reports recent
fevers
DISEASE
and coughs productive of white sputum as well as right sided
chest pain
DISEASE
. She developed
dyspnea
DISEASE
saying that her breathingis all right. She denied
chest pain
DISEASE
and
abdominal pain
DISEASE
. Ather nursing home she was diagnosed with
pneumonia
DISEASE
was givenZithromax on [**6-26**] initially 500 per day then 250 mgthereafter. Yesterday she continued to spike
fevers
DISEASE
. Shewas given ceftriaxone 1 gm. Her
fevers
DISEASE
curtailed throughoutthe day. Her blood pressure was recorded to be 84/40 and wastransferred to [**Hospital6 256**] forfurther evaluation. At [**Hospital3 **] she was given fluid tosupport her blood pressure. Her cultures were drawn and wasgiven levofloxacin and Flagyl for presumed
pneumonia
DISEASE
. TheMedical Intensive Care Unit was called to evaluate thepatient for low blood pressure and after 4 liters of fluidher blood pressures did not significantly improve.PAST MEDICAL HISTORY:1. Severe
rheumatoid arthritis
DISEASE
2. Lower
gastrointestinal bleed
DISEASE
from
gastritis
DISEASE
in '[**36**]3. Decubiti
ulcers
DISEASE
4. Congestive
heart failure
DISEASE
MEDICATIONS:1. Zithromax 250 mg2. Albuterol nebulizers q63. Robitussin 10 cc qid for five days4. Ceftriaxone 1 gm multivitamin qd5. Lasix 2 mg po qd6. Iron 325 mg po qd7. Prevacid 50 mg [**Hospital1 **]8. Tylenol 650 mg po tid9. Capoten 6.25 mg po tidALLERGIES: She is not
allergic
DISEASE
to any medication.SOCIAL HISTORY: She is a nursing home resident. She quitsmoking 60 years ago.FAMILY HISTORY: Noncontributory.REVIEW OF SYSTEMS: As above.PHYSICAL
EXAM
DISEASE
:VITAL SIGNS: On admission her temperature was 101.8Admission Date: [**2180-6-12**] Discharge Date: [**2180-7-5**]Service: VASCULAR SURGERYCHIEF COMPLAINT: Ischemic right fifth toe
ulcer
DISEASE
.HISTORY OF PRESENT ILLNESS: This is a 79-year-old whitefemale with
coronary artery disease
DISEASE
status post myocardial
infarction
DISEASE
with coronary artery bypass grafting in [**2170**]
myocardial infarction
DISEASE
with
congestive heart failure
DISEASE
in[**2179-11-9**] with
diabetes end-stage renal disease
DISEASE
onhemodialysis status post left above-knee amputation in [**2175**]who complained of an eight-month history of right forefootulceration. In spite of treatment the patient's left fifthtoe ulceration has not healed.Over the previous week prior to admission the patient notedchanges in the color of her right toes. She denied rest
pain
DISEASE
. She complained of prior symptoms of right lower
extremity claudication
DISEASE
although currently she is wheelchairbound. She has a left lower extremity prosthesis which shedoes not use.The patient was seen in the office a week prior to admissionand scheduled for admission and elective revascularization ofher right leg.PAST MEDICAL HISTORY:1. Coronary artery diseaseAdmission Date: [**2135-1-31**] Discharge Date: [**2135-2-3**]Date of Birth: [**2065-8-18**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4052**]Chief Complaint:
Respiratory distress
DISEASE
.Major Surgical or Invasive Procedure:None.History of Present Illness:69yoF with T8
paraplegia
DISEASE
who presented to the ED with 6 days ofAdmission Date: [**2135-12-12**] Discharge Date: [**2135-12-14**]Date of Birth: [**2065-8-18**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2297**]Chief Complaint:Mental status changeMajor Surgical or Invasive Procedure:IntubationHistory of Present Illness:HPI: Ms. [**Known lastname 4636**] is a 70 yo female with h/o
paraplegia HTN
DISEASE
and Admission Date: [**2136-9-11**] Discharge Date: [**2136-9-15**]Date of Birth: [**2065-8-18**] Sex: FService: MEDICINE
Allergies
DISEASE
:Adhesive TapeAttending:[**First Name3 (LF) 4052**]Chief Complaint:Mental status change
abdominal pain
DISEASE
Major Surgical or Invasive Procedure:Flexible SigmoidoscopyRight IJ intravenous catheter placementHistory of Present Illness:Ms. [**Known lastname 4636**] is a 71 yo wheel-chair bound woman with
paraplegia hypertension
DISEASE
and question of
COPD
DISEASE
who was admittedon [**9-11**] with altered mental status. Per the patient she hadbeen experiencing
constipation
DISEASE
for 5-6 days prior to admission.She did have a small BM on the morning of admission. On the dayof admission the patient reported feeling sweaty and dizzy anddropped a cup of tea onto her lap. Her neighbor who wasvisiting noticed she was weak and dysarthric and calledlifeline who then brought the patient to the ED..In the ED her initial vitals were temp 99.5 bp 113/44 HR 96RR 16 SaO2 96% on
NRB
DISEASE
. Her bp decreased to
81/38
DISEASE
in the ED andshe became unable to respond to commands so she was given 4 LNS. Her bp slightly improved to
91/45
DISEASE
. She also had a largeloose BM in ED. A right IJ was placed. UA was nitrite positivewith moderate bacteria. CXR was concerning for left lower lobe
pneumonia
DISEASE
. The patient was thought to have
sepsis
DISEASE
[**1-6**] to PNAvs.
UTI
DISEASE
and she was given Vancomycin 1 mg IV x1 Levaquin 750mg IV x1 and Tylenol PR 1 gm x1 and transferred to the MICU..In the MICU the patient was started on Levophed for pressuresupport. WBC 19.6 with a left shift Lactate 3.4 -Admission Date: [**2137-7-2**] Discharge Date: [**2137-7-9**]Date of Birth: [**2065-8-18**] Sex: FService: MEDICINE
Allergies
DISEASE
:Adhesive TapeAttending:[**First Name3 (LF) 2009**]Chief Complaint:
Hypotension
DISEASE
Major Surgical or Invasive Procedure:RIJ placementHistory of Present Illness:Ms. [**Known lastname 4636**] is a 71yo paraplegic female with PMH significantfor
HTN
DISEASE
HLD and chronic UTI's who is being transferred to theMICU for management of
hypotension
DISEASE
. Per her sonthe patient's home nurse noted that she had a slight temperaturethis morning. Her son noted that her appetite was poor and wasalso incoherent. He also noted that her catheter contained urinethat was dark and concentrated. He immediately called 911. Shewas then brought to [**Hospital1 18**] ED for further work-up. There is noreport of SOB
chest pain abdominal pain diarrhea
DISEASE
or
constipation
DISEASE
. The son was also concerned that her catheter wasnot working well and needed to be changed.In the ED initial vitals were T 102.2 BP 115/33 AR 105 RR 18 O2
sat 94% on 3L NC. She received Vancomycin 1gm IV Zosyn 4.5gmIV and Tylenol 1gm. Her blood pressure dropped to 95/43 andgiven lack of improvement after receiving 3L NS she is beingtransferred to the MICU for closer monitoring.Past Medical History:1)Paraplegia [**1-5**] Anterior Spinal
Infarct
DISEASE
2)Thoracic
Aneurysm
DISEASE
Repair ([**2128**])3)Hx of LLL Collapse/PNA s/p mucous plug removal viabronchoscopy4)HTN
5)Hyperlipidemia
DISEASE
6)GERD7)Suprapubic Catheter Placement /
UTIs
DISEASE
on Ppx Bactrim8)Fecal Incontinence9)DepressionSocial History:58 year tobacco history now smoking 3 cigarettes per daydenies EthOH denies
drug abuse
DISEASE
. Widowed. Has 3 sons. Shelives alone in [**Hospital3 4634**].Family History:Son has DMPhysical Exam:vitals T 95.8 BP 117/50 AR 65 RR 23 O2 sat 95% on 3L NCGen: Patient awake responsive to commandsHEENT: MMM PERRLAHeart: RRR no audible mrgLungs: CTAB scattered crackles at posterior basesAbdomen: Markedly distended but soft NT Admission Date: [**2137-11-6**] Discharge Date: [**2137-11-20**]Date of Birth: [**2065-8-18**] Sex: FService: MEDICINE
Allergies
DISEASE
:Adhesive TapeAttending:[**First Name3 (LF) 4654**]Chief Complaint:Altered mental
status hypotension hypoxia
DISEASE
.Major Surgical or Invasive Procedure:CT-guided drainage of left gluteal abscess ([**2137-11-15**]).History of Present Illness:Mrs. [**Known lastname 4636**] is a 72 y/o woman with PMH notable for
paraplegia
DISEASE
[**1-5**] anterior spinal artery infarct indwelling suprapubiccatheter with frequent
UTIs
DISEASE
admitted with altered mental statusand
hypoxia
DISEASE
. Per nursing facility notes the patient was notedto be unresponsive to voice commands but responsive to tactilestimuli. Vitals at the time were BP 100/50 HR 100 RR 20 O280% on
RA
DISEASE
which increased to 97% on 6 L NC. Reportedly she isalert & oriented X 3 at her baseline. Of note she is currentlyon nitrofurantoin 100 mg PO BID for a
UTI
DISEASE
(Admission Date: [**2138-10-15**] Discharge Date: [**2138-10-23**]Date of Birth: [**2065-8-18**] Sex: FService: MEDICINE
Allergies
DISEASE
:Adhesive TapeAttending:[**First Name3 (LF) 905**]Chief Complaint:
Fever
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:73F with
paraplegia
DISEASE
recurrent
UTI
DISEASE
chronic sacral decubspresenting with
fever
DISEASE
and altered mental status. She was seen byher NP yesterday with
fever
DISEASE
to 102 and positive UA. Her sacraldecub was noted to be improved since last exam. Cipro startedfor
UTI
DISEASE
. Also seen by her visiting nurse today and son reportedthat overnight she was confused talking about getting up towalk (though paraplegic) and Admission Date: [**2196-3-5**] Discharge Date: [**2196-4-20**]Date of Birth: [**2127-1-18**] Sex: MService: [**Last Name (un) **]CHIEF COMPLAINT: Fevers
chills abdominal pain
DISEASE
in the rightupper quadrant worsening shortness of breath x1 day
pleuritic like chest pain
DISEASE
and
nausea
DISEASE
.HISTORY OF PRESENT ILLNESS: The patient is a 69-year-oldmale with a history of
polycystic kidney disease
DISEASE
status postcadaveric renal transplant in [**2190**] on Rapamune prednisoneand Gengraf. The patient has a history of
polycystic liver
DISEASE
disease with recent
cyst infections
DISEASE
treated with IVantibiotics recently presents with 2 week history of
fevers
DISEASE
up to 101
chills malaise
DISEASE
and
shortness of breath
DISEASE
withincreasing
abdominal distention
DISEASE
and right upper quadrant
pain
DISEASE
. The patient saw Dr. [**First Name (STitle) **] in the clinic the weekprior and was instructed to go to the hospital for furtherevaluation. The patient felt worse however and came to theemergency department for evaluation and workup. The patientcomplained of
malaise and shortness of breath
DISEASE
but denied
chest pain
DISEASE
. He denied any
anorexia
DISEASE
or urinary symptoms or newbowel changes. He did complain of
nausea
DISEASE
and some
dry heaves
DISEASE
.The patient has a history of
polycystic kidney disease
DISEASE
withalso
polycystic liver disease
DISEASE
with multiple large livercysts one of which became infected secondarily with apansensitive pseudomonas following episode of ERCP induced
cholangitis
DISEASE
and
bacteremia
DISEASE
in [**2195-8-20**]. At that timehe was initially treated with PIP/TAZO followed byrecurrence of
fevers
DISEASE
and persistence of the abscess. He wasdrained in [**2195-10-20**] and treated with 6 weeks of Ciproplus 2 weeks of Augmentin for an unidentified gram positivecocci through late [**Month (only) 404**]. He did well through [**2196-2-17**]when he had recurrent
low fevers
DISEASE
and malaise. Repeat MRIshowed enlargement of the left lateral
liver abscess
DISEASE
that wasimpinging on the diaphragm and pericardium. He was started onoral Cipro as an outpatient. He continued to have low grade
fevers
DISEASE
.ALLERGIES: No known
drug allergies
DISEASE
.PAST MEDICAL HISTORY:
Polycystic kidney disease
DISEASE
hypertension GERD endstage renal disease
DISEASE
status postcadaveric renal transplant in [**2190**]
CHF biliary stones
DISEASE
diverticulosis
DISEASE
chronic
pancreatitis cholestasis
DISEASE
.PAST SURGICAL HISTORY: Cadaveric renal transplant in [**2190**]biliary stenting and an
AV fistula
DISEASE
.MEDICATIONS: At home prednisone 5 mg Lopressor 75 mg p.o.b.i.d. cyclosporin 25 mg b.i.d. doxazosin Rapamune 1 mgp.o. daily Protonix allopurinol 50 mg p.o. b.i.d. Lasix 20mg p.o. daily and Bactrim single strength daily.The patient was admitted to the transplant service. Full labswere sent off. A KUB and chest x-ray were done thatdemonstrated massive
cardiomegaly
DISEASE
and
pericardial effusion
DISEASE
.Blood cultures and urine cultures were sent. These weresubsequently negative.PHYSICAL EXAMINATION: On admission temperature was 99.7heart rate 89 blood pressure 133/68 respiratory rate 24 O2
saturation 96% in room air. He was mildly uncomfortableappeared uncomfortable. No scleral icterus. EOMI. Respiratoryrate regular. Lungs were decreased on the left base with endexpiratory crackles at base. He was tachypneic especiallywhen supine. Heart: Regular rate and rhythm no murmurs butdistant sounds. Abdomen moderately distended tender overright upper quadrant. He was tympanitic no rebound noguarding. Extremities: Warm no
clubbing cyanosis
DISEASE
1Unit No: [**Numeric Identifier 4666**]Admission Date: [**2196-6-29**]Discharge Date: [**2196-7-24**]Date of Birth: [**2127-1-18**]Sex: MService:Per dictator: Admission Date: [**2176-8-17**] Discharge Date: [**2176-8-21**]Date of Birth: [**2114-2-8**] Sex: MService:CHIEF COMPLAINT: Respiratory distress.HISTORY OF PRESENT ILLNESS: The patient is a 62-year-oldmale with a past medical history significant for
lung cancer
DISEASE
status post right pneumonectomy in [**2175-6-28**] sixhospitalizations since [**2176-5-27**] last discharged on[**2176-8-4**] with the diagnosis of
tracheal bronchitis
DISEASE
versus
chronic obstructive pulmonary disease
DISEASE
flare versusatypical
pneumonia
DISEASE
status post intubation in the MICUchronic secretions/congestion-related problems onalternating regimen of Augmentin and Bactrim since [**2175-9-28**] for
multiple bronchitic-like infections
DISEASE
chronic
obstructive pulmonary disease congestive heart failure
DISEASE
atrial fibrillation
DISEASE
prior PEs diabetes type 2 status post
myocardial infarction
DISEASE
who presented with gradual shortnessof breath beginning on the day of admission.The patient reported a [**1-29**] day history of general
fatigue
DISEASE
.On the day of admission visiting nurse services reported asystolic blood pressure of 70. The wife drove the patient tothe Emergency Room. The patient also complained of some
dizziness
DISEASE
however denied other symptoms including
fever
DISEASE
chills sweats chest pain diarrhea constipation nausea
DISEASE
vomiting
DISEASE
or urinary symptoms. He reported good p.o. intakeand appetite.The patient reported that he has a chronic slight
cough
DISEASE
however denied any sputum production. He took his oraltemperature at home and denied any
fever
DISEASE
. At home thepatient is on oxygen of [**12-31**] L via nasal cannula. The patientrecently finished a steroid taper on [**8-14**] which wastwo weeks in length. He reported a usual SBP of 80-110. Thepatient did note that since [**Month (only) 216**] a Scopolamine patch wasadded to his regimen and has increased his secretionssignificantly.EMERGENCY DEPARTMENT COURSE: Per Emergency Room the patientappeared close to intubation upon presentation and was placedon 100% oxygen via non-rebreather with an ABG of 7.46 pCO2of 48 and pO2 of 33. There was a question if this was avenous gas or not. Lasix 100 mg IV Albuterol nebsSolu-Medrol 600 mg IV and Ceftriaxone 1 g IV was given tothe patient. When evaluated by the MICU shortly afterarrival to the Emergency Room the patient was weaned down tobaseline of 2 L oxygen with oxygen saturation of 100% vianasal cannula. The patient was breathing comfortably at18-20 breaths/min. The patient no longer complained of
shortness of breath
DISEASE
but did state that he felt slightlytired. Chest x-ray was negative and a CT showed no acutePE. The patient reported that he was back to baseline in theEmergency Room.PAST MEDICAL HISTORY: 1. Stage III
squamous cell lung
DISEASE
cancer
DISEASE
diagnosis in [**2175-2-26**] status post rightpneumonectomy in [**2175-6-28**] with radiation Carboplatinand Taxol treatments. 2. Chronic obstructive pulmonarydisease with PFTs in [**2176-5-27**] showing an FEV1 of 0.83 Lwhich is 25% of predicted and FEV1 to FVC ration of 68% ofpredicted. 3. Congestive
heart failure
DISEASE
with preserved leftventricular function in [**2176-5-27**]. 4.
Atrial fibrillation
DISEASE
.This was noted perioperatively. 5.
Prostate carcinoma
DISEASE
diagnosed in [**2172-2-26**] status post radical prostatectomy in[**2172-8-27**]. 6. Diabetes type 2. 7. History of
urosepsis
DISEASE
. 8. History of PE during the patient'spostoperative course in [**2175-6-28**]. 9. Status post
myocardial infarction
DISEASE
. This was also perioperative in [**2175-6-28**]. Catheterization at that time showed normal leftventricular function ejection fraction of 50% and a 30%right
coronary artery lesion
DISEASE
. 10. Status post transientischemic attack in [**2165**]. 11. Gout. 12. Gastroesophageal
reflux disease
DISEASE
. 13. Sleep apnea. 14. Colonic polyps notedin [**2173-5-27**]. 15.
Hypercholesterolemia
DISEASE
.ALLERGIES: Doxepin causes
delirium
DISEASE
. Levaquin causesprolonged QTCs. OxyContin causes Unit No: [**Numeric Identifier 4669**]Admission Date: [**2167-8-11**]Discharge Date: [**2167-8-15**]Date of Birth: [**2091-6-8**]Sex: MService:HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 76-year-old manwith a history of
hypertension dyslipidemia
DISEASE
and coronary
artery disease
DISEASE
(status post
inferior myocardial infarction
DISEASE
with
ventricular fibrillation arrest
DISEASE
in [**2156**]) who has donewell with only six episodes of
exertional angina
DISEASE
until then.Three days ago the patient woke up at 3:00 a.m. with severemidsternal
chest pain
DISEASE
radiating to the left arm. It wassimilar to the symptoms of his prior
myocardial infarction
DISEASE
.It was not associated with
nausea vomiting diarrhea
DISEASE
or
shortness of breath
DISEASE
.The patient presented to [**Hospital **] Hospital within one halfhour of the onset of the
pain
DISEASE
where he was treated withsublingual nitroglycerin oxygen morphine and heparin. Thepatient became
pain
DISEASE
free and remained so for the remainder ofhis hospitalization. The patient ruled in for a myocardial
infarction
DISEASE
with a positive troponin level of 2.87 and acreatine kinase of 426.Cardiac catheterization performed on the day prior toadmission at [**Hospital **] Hospital demonstrated a small LIMAtotal occlusion of the SVG to OM and diseased segments ofthe SVG to diagonal to obtuse marginal. The ejectionfraction was normal. The LV end-diastolic pressure was 19right atrial pressure was 13 and pulmonary artery pressure33/10.The patient was transported to [**Hospital1 188**] on the day of admission where he underwent stenting ofthe saphenous vein graft to diagonal and obtuse marginal witha PercuSurge distal protection device. The patientexperienced his typical
anginal symptoms
DISEASE
during the procedureand for approximately one hour status post procedure.The patient denied a history of
shortness of breath dyspnea
DISEASE
on exertion paroxysmal
nocturnal dyspnea orthopnea
DISEASE
palpitations lightheadedness syncope
DISEASE
or
presyncope
DISEASE
.PAST MEDICAL HISTORY:1. Coronary artery diseaseAdmission Date: [**2118-9-22**] Discharge Date: [**2118-10-9**]Date of Birth: [**2042-5-18**] Sex: MService:CHIEF COMPLAINT: Expanding
infrarenal abdominal
DISEASE
aortic
aneurysm
DISEASE
.HISTORY OF PRESENT ILLNESS: The patient is a 76-year-oldmale with a known 6.5 x 5.5 cm infrarenal abdominal aortic
aneurysm
DISEASE
who presented to the emergency department afterexperiencing
weakness
DISEASE
and
diaphoresis
DISEASE
while at his dentist'soffice. He was also complaining of severe bilateral lowerextremity claudication and
back pain
DISEASE
for two weeks. He tooknitroglycerin at the dentist's office with some relief andwas sent to the emergency department for evaluation.PAST MEDICAL HISTORY:1. Coronary
artery disease
DISEASE
status post myocardial
infarctions
DISEASE
in [**2091**] [**2079**] and [**2059**].2. Cerebrovascular accident.3. Chronic
obstructive pulmonary disease
DISEASE
.4. Hypertension.5. Peripheral
vascular disease
DISEASE
.6. Infrarenal
abdominal aortic aneurysm
DISEASE
6.5 x 5.5 cm.ALLERGIES: None known.MEDICATIONS ON ADMISSION:1. Toprol 300 mg qd2. Lipitor 10 mg qd3. Imdur 120 mg qd4. Vioxx 25 mg qd5. Norvasc 25 mg qd6. Pepcid 20 mg qd7. Singulair 10 mg8. .............. 100 mg b.i.d.9. Lasix 20 mg qd10. Allopurinol 100 mg qd11. .............. 60 mg qd12. Trental 400 mg t.i.d.13. Zoloft 25 mg qd14. Antivert 12.5 mg qd15. Flovent 10 mgPHYSICAL EXAMINATION ON ADMISSION: Blood pressure 138/88heart rate 72 and irregular 98% on two liters. GeneralExam: Obese male. HEENT: EOMI. MMM. Cardiovascular:Irregular heart rate. Lungs: Clear to auscultationbilaterally. Abdomen: Obese soft tender. Pulsatile mass.Rectal: Guaiac negative normal tone. Extremities:Palpable radials left femoral left popliteal left dorsalispedis left posterior tibial palpable.LABS ON ADMISSION: Chemistries showed sodium 144 potassium4.6 chloride 108 bicarbonate 22 BUN 31 creatinine 1.9glucose 121. CBC showed hematocrit 44.5 white cell count11.3 platelets 175000. Coagulations: PT 13.1 PTT 6.1INR 1.1Electrocardiogram on admission showed
atrial fibrillation
DISEASE
.HOSPITAL COURSE: The patient was diagnosed as having anexpanding
infrarenal abdominal aortic aneurysm
DISEASE
and wasadmitted to the Vascular Intensive Care Unit VICU formonitoring and preparation for surgery on the following day.A Cardiology consult was obtained and they recommendedshort-acting beta blocker therapy.On [**2118-9-23**] he underwent an
abdominal aortic aneurysm
DISEASE
resection with oversewing of the left CIA ligation of right
CIA
DISEASE
aortobifemoral with profunda bypass with bifurcatedDacron graft. Postoperatively he remained intubated forhemodynamic monitoring and was transferred to the PACU andstarted on Lopressor drip.On postoperative day #1 he was extubated and transferred tothe Surgical Intensive Care Unit for further monitoring. Onpostoperative day #1 his urine output was low and he wasdiagnosed as having
ATN
DISEASE
and seemed to be fluid overloaded.He responded to Lasix. It was also noted that his cardiacenzymes were elevated and he was ruled in with a non-Q waveMI. He was then started on Cardiology recommendations onaspirin and continued beta blockade.He was relatively stable over the next couple of daysalthough he was requiring blood transfusions on a frequentbasis. Postoperative echocardiogram on [**2118-9-26**] revealed anEF of less than 25% (preoperatively about 35%) and globalhypokinesis of the left ventricle mild pulmonary
hypertension
DISEASE
1Admission Date: [**2118-9-22**] Discharge Date: [**2118-10-9**]Date of Birth: [**2042-5-18**] Sex: MService:CHIEF COMPLAINT: Expanding
infrarenal abdominal
DISEASE
aortic
aneurysm
DISEASE
.HISTORY OF PRESENT ILLNESS: The patient is a 76-year-oldmale with a known 6.5 x 5.5 cm infrarenal abdominal aortic
aneurysm
DISEASE
who presented to the emergency department afterexperiencing
weakness
DISEASE
and
diaphoresis
DISEASE
while at his dentist'soffice. He was also complaining of severe bilateral lowerextremity claudication and
back pain
DISEASE
for two weeks. He tooknitroglycerin at the dentist's office with some relief andwas sent to the emergency department for evaluation.PAST MEDICAL HISTORY:1. Coronary
artery disease
DISEASE
status post myocardial
infarctions
DISEASE
in [**2091**] [**2079**] and [**2059**].2. Cerebrovascular accident.3. Chronic
obstructive pulmonary disease
DISEASE
.4. Hypertension.5. Peripheral
vascular disease
DISEASE
.6. Infrarenal
abdominal aortic aneurysm
DISEASE
6.5 x 5.5 cm.ALLERGIES: None known.MEDICATIONS ON ADMISSION:1. Toprol 300 mg qd2. Lipitor 10 mg qd3. Imdur 120 mg qd4. Vioxx 25 mg qd5. Norvasc 25 mg qd6. Pepcid 20 mg qd7. Singulair 10 mg8. .............. 100 mg b.i.d.9. Lasix 20 mg qd10. Allopurinol 100 mg qd11. .............. 60 mg qd12. Trental 400 mg t.i.d.13. Zoloft 25 mg qd14. Antivert 12.5 mg qd15. Flovent 10 mgPHYSICAL EXAMINATION ON ADMISSION: Blood pressure 138/88heart rate 72 and irregular 98% on two liters. GeneralExam: Obese male. HEENT: EOMI. MMM. Cardiovascular:Irregular heart rate. Lungs: Clear to auscultationbilaterally. Abdomen: Obese soft tender. Pulsatile mass.Rectal: Guaiac negative normal tone. Extremities:Palpable radials left femoral left popliteal left dorsalispedis left posterior tibial palpable.LABS ON ADMISSION: Chemistries showed sodium 144 potassium4.6 chloride 108 bicarbonate 22 BUN 31 creatinine 1.9glucose 121. CBC showed hematocrit 44.5 white cell count11.3 platelets 175000. Coagulations: PT 13.1 PTT 6.1INR 1.1Electrocardiogram on admission showed
atrial fibrillation
DISEASE
.HOSPITAL COURSE: The patient was diagnosed as having anexpanding
infrarenal abdominal aortic aneurysm
DISEASE
and wasadmitted to the Vascular Intensive Care Unit VICU formonitoring and preparation for surgery on the following day.A Cardiology consult was obtained and they recommendedshort-acting beta blocker therapy.On [**2118-9-23**] he underwent an
abdominal aortic aneurysm
DISEASE
resection with oversewing of the left CIA ligation of right
CIA
DISEASE
aortobifemoral with profunda bypass with bifurcatedDacron graft. Postoperatively he remained intubated forhemodynamic monitoring and was transferred to the PACU andstarted on Lopressor drip.On postoperative day #1 he was extubated and transferred tothe Surgical Intensive Care Unit for further monitoring. Onpostoperative day #1 his urine output was low and he wasdiagnosed as having
ATN
DISEASE
and seemed to be fluid overloaded.He responded to Lasix. It was also noted that his cardiacenzymes were elevated and he was ruled in with a non-Q waveMI. He was then started on Cardiology recommendations onaspirin and continued beta blockade.He was relatively stable over the next couple of daysalthough he was requiring blood transfusions on a frequentbasis. Postoperative echocardiogram on [**2118-9-26**] revealed anEF of less than 25% (preoperatively about 35%) and globalhypokinesis of the left ventricle mild pulmonary
hypertension
DISEASE
1Admission Date: [**2105-9-8**] Discharge Date: [**2105-9-16**]Date of Birth: [**2053-8-14**] Sex: MService: NEUROSURGERY
Allergies
DISEASE
:seasonalAttending:[**First Name3 (LF) 1271**]Chief Complaint:neck and bilateral arm
pain
DISEASE
Major Surgical or Invasive Procedure:[**2105-9-8**]: Anterior cervical removal of hardware and loosescrews[**2105-9-8**]: Neck exploration Repair of pharynx directlaryngoscopyHistory of Present Illness:Patient comes in today for discussion of surgery - revision ofcervical fusion that is scheduled for this week. Patient stateshe has
pain
DISEASE
in his neck to 2 inches below his elbow bilateral.He states that the
pain
DISEASE
in his neck is sharp shooting in natureand the arms are a constant
dull ache
DISEASE
. Left side is worse and hefeels his neck cracking. He was initially seen[**2105-5-21**]. He also notes difficulty swallowingCT reviewed at that visit. Per Dr.[**Name (NI) 4674**] note: Priorsurgery with a plate lying anterior at the C4 through C6 levels.The screws at C5 are slightly inferior placed. There is probablynonunion at C4-C5. There are two completely extruded screwsinferior to that plate probably coming from the C4 and C5 areas.They are in close contact with the esophagus and potentiallycausing the symptoms of
dysphagia
DISEASE
.The risks and benefits of undergoing surgical intervention werediscussed with the patient. He now electively presents for ACDFrevision.Past Medical History:1. Recurrent
syncope
DISEASE
of unclear etiology with no
arrhythmia
DISEASE
identified on extended monitoring with a Reveal implantedmonitor2. Single brief episode of
atrial fibrillation
DISEASE
3.
Hypertension
DISEASE
4.
Hyperlipidemia
DISEASE
5.
Obesity
DISEASE
6.
COPD
DISEASE
(PFT's [**2-/2105**]: moderately severe
obstructive defect
DISEASE
withsignificant improvement in bronchodilator mild reduction indiffusing capacity)7. Prior failed cervical fusion (C3-C5) with implanted hardware8. History of heavy alcohol use9.
Chronic pain
DISEASE
10. benign
prostatic hypertrophy
DISEASE
11. Anxiety/depression12. Multiple prior
infections
DISEASE
(Reveal pocket
cystitis
DISEASE
multiple
abscesses prostatitis
DISEASE
)13.
Dysphagia
DISEASE
14. Tobacco abuseSocial History:smokes 1ppd ongoing 13 years admits to 3 beers a night. He wasa manager in retail now applying for disabilityFamily History:non-contributoryPhysical Exam:From clinic [**8-12**]Gen: anxious uncomfortable gentleman in no acute distress. HR100 and BP 146/100HEENT: Pupils: PERRL EOMs intactExtrem: Warm and well-perfused. No C/C/E.Neuro:Mental status: Awake and alert cooperative with exam normalaffect.Orientation: Oriented to person place and date.Language: Speech fluent with good comprehension and repetition.Cranial Nerves:I: Not testedII: Pupils equally round and reactive to light Visual fieldsarefull to confrontation.III IV VI:
Extraocular movements
DISEASE
intact bilaterally without
nystagmus
DISEASE
.V VII: Facial strength and sensation intact and symmetric.VIII: Hearing intact to finger rub bilaterally.IX X:
Palatal elevation
DISEASE
symmetrical.[**Doctor First Name 81**]: Sternocleidomastoid and
trapezius
DISEASE
normal bilaterally.XII: Tongue midline without
fasciculations
DISEASE
.Motor: Normal bulk and tone bilaterally. No
abnormal movements
DISEASE
tremors
DISEASE
. Strength full power [**5-30**] throughout except in shoulders[**4-30**]. No pronator drift. Gait is slowSensation: Intact to light touchReflexes: 3 Admission Date: [**2198-6-17**] Discharge Date: [**2198-7-6**]Date of Birth: [**2149-8-22**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2160**]Chief Complaint:
Sepsis
DISEASE
Major Surgical or Invasive Procedure:HD cath placementPICC line placementHistory of Present Illness:48M in USOH until two nights ago developed Admission Date: [**2185-12-22**] Discharge Date: [**2186-1-4**]Service:HISTORY OF PRESENT ILLNESS: The patient is an 88 year-oldfemale with a history of
coronary artery disease
DISEASE
status postcoronary artery bypass graft times two congestive heartfailure with ejection fraction of 35% paroxysmal atrial
fibrillation
DISEASE
status post DDD pacer placement admitted[**2185-12-22**] with sudden onset of right eye
pain
DISEASE
at home. Shesubsequently developed
slurred speech
DISEASE
and was taken to theEmergency Department via EMS. In the Emergency Departmentthe patient was noted to have
slurred speech
DISEASE
and a left
hemiparesis
DISEASE
. CAT scan was negative for
hemorrhage
DISEASE
butpositive for a probable
embolic right MCA stroke
DISEASE
. TPA wasadministered in the Emergency Department without benefit.The patient developed
respiratory distress
DISEASE
in the EmergencyDepartment requiring supplemental oxygen Lasix and a trialof a noninvasive ventilator.The patient was subsequently transferred to the MICU. Bloodpressure was elevated on admission to 160 to 180. Symptomsof
congestive heart failure
DISEASE
were controlled with anitroglycerin drip initially. Neurological examinationrevealed complete left sided
hemiplegia
DISEASE
with decreasedsensation of the left arm and a left facial droop. Thepatient has required no further diuresis in the MICU. Bloodpressures were running in the 120s to 130s. Nitroglycerindrip was discontinued on [**2185-12-22**] upon arrival to the MedicalIntensive Care Unit. Speech and swallow evaluation on[**2185-12-23**] recommended nectar thick liquids since the patientwas considered to be at aspiration risk. A repeat head CT on[**12-22**] showed a large right MCA stroke unchanged from prior.The patient's creatinine was slightly increased frombaseline but her urine output was good. An increased whiteblood cell count was noted on [**12-22**] considered to be stressresponse versus evidence of
infection
DISEASE
and cultures were sent.On [**12-22**] and [**12-23**] the patient was noted to have increasedalertness complaining of a
headache
DISEASE
with an unchangedneurological examination. On [**12-23**] systolic blood pressurewas running 100 to 110 with the head of the bed at 30 degreeselevation. The patient was alert and interactive though notopening her eyes. She was subsequently transferred to thefloor.PAST MEDICAL HISTORY: 1. Coronary artery disease statuspost coronary artery bypass graft times two in [**2181**]complicated by a left
ventricular aneurysm
DISEASE
status postpatched graft and third degree
heart block
DISEASE
. 2. History ofparoxysmal
atrial fibrillation
DISEASE
status post DDD pacer. 3.
Congestive heart failure
DISEASE
with ejection fraction of 35%. 4.
Hypertension
DISEASE
. 5. Hyperthyroid. 6. Chronic renalinsufficiency with a baseline creatinine of 1.4.MEDICATIONS AT HOME: Cozaar 25 mg po q.d. Lasix 40 mg poq.d. enteric coated aspirin Ambien Lipitor Levoxyl.MEDICATIONS AT MICU: Protonix 40 mg q.d. Tylenol subQheparin and enteric coated aspirin.ALLERGIES: No known
drug allergies
DISEASE
.PHYSICAL EXAMINATION ON TRANSFER FROM THE MICU: Vital signstemperature 98.2. Pulse 61. Blood pressure 121/56.Respiratory rate 20. Pulse ox 100% on room air.Examination the patient is lying in bed with her eyesclosed unable to open them but is interactive and respondsto questions and commands. Mental status the patient isoriented to hospital state but not year. She is orientedto the reason for her hospitalization and answers questionsappropriately. HEENT she has dry oral mucosa. The tongue ismidline. She is unable to raise her eyelids. The pupils arepoorly reactive bilaterally but the patient does respond tolight stimuli. There is poor response to threat bilaterally.We were unable to assess visual fields and extraocularmovements at this time. Neck was supple with no bruits.Cardiovascular regular 2 out of 6 systolic murmur best atthe right upper sternal border. Lungs were with rhoncerousbreath sounds bilaterally in the anterior lung fields.Abdomen is soft mild diffuse tenderness to palpation withno rebound or guarding and
active bowel sounds
DISEASE
. Extremitiesno
edema
DISEASE
. There are several small raised red lesions on thedistal lower extremities.Neurological examination the patient's sensation is intact.The patient is able to open her jaw against resistance andshrug her shoulders. She has a left sided visual fielddefect/neglect. Sensation there is no response to lighttouch to the left arm. She does sense touch on the rightarm. Light touch sensation is intact bilaterally in thelower extremities. Strength of the left arm is
flaccid
DISEASE
with0 out of 5 strength. The left leg is also
flaccid
DISEASE
. Theright arm shows 5 out of 5 biceps and triceps. The right leg3 out of 5 hip extension 5 out of 5 ankle flexion andextension. Reflexes biceps 2Admission Date: [**2130-11-14**] Discharge Date: [**2130-11-27**]Date of Birth: [**2058-9-27**] Sex: FService: SURGERY
Allergies
DISEASE
:Latex / Penicillins / Sulfa (Sulfonamide Antibiotics)Attending:[**First Name3 (LF) 4691**]Chief Complaint:Abdominal painAdmission Date: [**2161-7-15**] Discharge Date: [**2161-7-19**]Date of Birth: [**2124-7-27**] Sex: FService: NEUROSURGERY
Allergies
DISEASE
:Shellfish / ScopolamineAttending:[**First Name3 (LF) 1835**]Chief Complaint:
headache
DISEASE
Major Surgical or Invasive Procedure:[**2161-7-15**] DECOMPRESSION CRANIECTOMY FOR CHIARI MALFORMATION WITHDURAPLASTYHistory of Present Illness:36 yo F with a long-standing history of fronto-occipital
headaches
DISEASE
previously treated with NSAIDs and sumatriptan alsobeen seen at the
pain
DISEASE
clinic with trials of lidocaine andketorolac infusions as well as injections of lidocaine andsteroids all to no avail recently started on amitryptiline 10mgpo daily.She notes a history of
headaches
DISEASE
since adolescence and thesehave continued to progress. She complains of a constant
headache
DISEASE
of moderate severity which is bilateral and fronto-occipital.However whenever she performs any type of Valsalva including
coughing sneezing
DISEASE
or heavy lifting she notes a differentmore severe
headache
DISEASE
mostly occipital in nature with associated
nausea vomiting
DISEASE
photo/phonophobia and flashing lightssensation. She underwent an MRI on [**2161-5-4**] which showed a
Chiari I malformation
DISEASE
. This was followed by an MRI
C-spine
DISEASE
whichshowed no
syringomyelia
DISEASE
.Past Medical History:PAST MEDICAL HISTORY
hyperthyroid
DISEASE
no medsPAST SURGICAL HISTORY-T&A-ear tubes-bilateral urethral stents as a child-orthopedic surgery to R leg (4 total)Social History:nurse married 2 children social EtOH no tobacco butsignificant 2nd hand smoke growing up no illicitsFamily History:
ruptured cerebral aneurysm
DISEASE
requiring surgery in 50s
COPD
DISEASE
CAD ureteral reflux resulting in
ESRD
DISEASE
requiring kidneytransplantAdmission Date: [**2138-2-16**] Discharge Date: [**2138-2-17**]Service: MEDICINE
Allergies
DISEASE
:Codeine / EpinephrineAttending:[**First Name3 (LF) 2297**]Chief Complaint:Drug ingestion.Reason for MICU admission: Suspected
overdose
DISEASE
on verapamilmetformin.Major Surgical or Invasive Procedure:None.History of Present Illness:(History obtained via daughter)This 83 year old woman with a history of
dementia hypertension
DISEASE
and
diabetes
DISEASE
was taken to ED after it was discovered that shemay have taken three doses of all her morning medications.
Dementia
DISEASE
at baseline so unable to give details. Her son visitedthis AM at 10:30 and noticed his mother felt dizzy. He found anopen pill box and noticed doses for medications over three dayswere missing. She usually takes these medications at 8:30 AM. Onweekdays an aide helps her with this but on weekends thepatient takes the medications herself. Morning medicationsincluded: glucosamine Verapamil XL (180 per daughter) tylenol(1000 mg) namenda razadyne (an anticholinesterase inhibitor)and metformin 500 mg. They contact[**Name (NI) **] her PCP who advised tobring her to the ED. On arrival vital signs were: HR 95 BP173/87. FS 101. EKG unremarkable. She did have one episode of
diarrhea
DISEASE
and one episode of
vomiting
DISEASE
. She underwent charcoaltherapy on recommendation of toxicology consult and wassubsequently admitted to ICU for intensive monitoring..THe patient has not been
depressed
DISEASE
and there is no history ofher trying to harm herself..ROS:
Denies fevers chest pain dyspnea abdominal pain
DISEASE
. Admission Date: [**2190-3-4**] Discharge Date: [**2190-3-9**]Date of Birth: [**2114-7-18**] Sex: FService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2534**]Chief Complaint:s/p Fall down stairs with neck and back
pain
DISEASE
Major Surgical or Invasive Procedure:[**3-4**] Closed reduction an splinting bilateral radial
fractures
DISEASE
History of Present Illness:This is a 75 year old woman s/p mechanical fall down 15 stairsand was found at bottom of stairsAdmission Date: [**2177-11-25**] Discharge Date: [**2177-12-5**]Date of Birth: [**2114-2-8**] Sex: MService: [**Hospital1 139**]HISTORY OF PRESENT ILLNESS: The patient is a 63 year oldmale with a past medical history of
chronic obstructive
pulmonary disease lung cancer
DISEASE
status post rightpneumonectomy in [**2175-1-26**] complicated by pulmonary arterylaceration status post transtracheal catheter placement foroxygen and suctioning who was in his usual state of healthuntil [**2177-11-24**] when he developed
nausea
DISEASE
lower
abdominal pain
DISEASE
and
projectile vomiting
DISEASE
of
nonbloody emesis
DISEASE
.He presented to the [**Hospital6 256**]Emergency Room on [**2177-11-25**]. At that time he denied
diarrhea constipation fevers chills hematochezia
DISEASE
andbright red blood per rectum. He had dark stools at baselinesecondary to iron use. The stool was found to be guaiacpositive in the Emergency Department. In the EmergencyDepartment also his hematocrit value was 19 down from abaseline of 31 one month previously and he was
coagulopathic
DISEASE
with an INR of 9.8. Attempts to place a nasogastric tube inthe Emergency Department were unsuccessful. While in theEmergency Department he was transfused 4 units of packed redblood cells 2 units of fresh frozen plasma and got 2 mg ofsubcutaneous Vitamin K. The patient was admitted to theMedicine Floor. Repeat hematocrit several hours laterdropped to a value of 13. The nasogastric tube was placed onthe floor with nasogastric lavage negative for fresh blood.He was at that point transferred to the Medical IntensiveCare Unit. Workup while in the Medical Intensive Care Unitincluded two esophagogastroduodenoscopies both without freshblood or old blood but demonstrating a single raised 5 to 7cm esophageal nodule on an erythematous base at approximately25 cm. There was no evidence of stigmata of recent
bleeding
DISEASE
.He was stabilized with a total of seven units of packed redblood cells seven units of fresh frozen plasma and one unitof platelets. He also received intravenous fluidresuscitation with normal saline. Computerized tomographyscan of the abdomen was performed which was negative fordiverticuli
perforation
DISEASE
or
retroperitoneal bleed
DISEASE
.Colonoscopy performed later in the hospital course showedsome
polyps diverticulosis
DISEASE
of the sigmoid colon anddescending colon. Internal hemorrhoids were noted but nostigmata of recent
bleeding
DISEASE
. The patient's
coagulopathy
DISEASE
wasimproving. His hematocrit was stable and he was transferredto the General Medicine
Floor
DISEASE
on [**2177-11-28**]. Of noteprior to transfer he developed
swelling
DISEASE
of the right upperextremity and complained of
pain
DISEASE
of the right upperextremity. Doppler ultrasound was performed which showedevidence of a right axillary deep vein
thrombosis
DISEASE
.PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonarydiseaseAdmission Date: [**2193-3-24**] Discharge Date: [**2193-4-9**]Date of Birth: [**2134-8-28**] Sex: FService: SURGERY
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 301**]Chief Complaint:Crampy
abdominal pain
DISEASE
Major Surgical or Invasive Procedure:Right colectomy with cholecystectomy ([**3-26**])Percutaneous drain placement ([**4-1**])Re-exploration ([**4-2**])History of Present Illness:Ms [**Known lastname 4698**] is a 58-year-old woman complaining of abdominal
pain
DISEASE
a history of previous sigmoidectomy for diverticulardisease. The patient complains of
cramps
DISEASE
and
vomiting
DISEASE
when N/Gtube not to aspiration.Physical Exam:Pertinent positives/negatives on Admission mildly obese softabdomen. No Rebound/guarding. No
rigidity
DISEASE
. Light diffuse
tenderness
DISEASE
. No
hernia
DISEASE
.Pertinent Results:[**2193-3-24**] 12:30PM WBC-10.9 RBC-4.74 HGB-14.7 HCT-42.4 MCV-89MCH-31.1 MCHC-34.7 RDW-13.5[**2193-3-24**] 12:30PM NEUTS-79.9* LYMPHS-14.9* MONOS-3.3 EOS-1.7BASOS-0.2[**2193-3-24**] 12:30PM PLT COUNT-395[**2193-3-24**] 12:30PM ALT(SGPT)-32 AST(SGOT)-18 ALK PHOS-86 TOTBILI-0.6[**2193-3-24**] 12:30PM LIPASE-29[**2193-3-24**] 12:30PM GLUCOSE-126* UREA N-9 CREAT-0.7 SODIUM-138POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13[**2193-3-24**] 02:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEGGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5LEUK-NEGBrief Hospital Course:Patient underwent CT scan which was consistent with amesenteric mass near the cecum. Proceeded with exploratorylaparotomy with planned wedge resection of mesenteric massrequiring right colectomy on [**3-26**]. She underwent right colectomyfor obstructing ascending colon from an isolated giant
diverticula
DISEASE
. The patient atoperation noted to have a markedly inflamed gallbladderpathology consistent with
chronic cholecystitis
DISEASE
and opencholecystectomy was performed at that time. Postoperatively thepatient was evaluated for
tachycardia
DISEASE
and underwent a CATscan which was suggestive of a right upper quadrant fluidcollection. HIDA scan revealed a leak which was confirmed byERCP. Endoscopic biliary stents were placed for better drainageof a duct of Luschka leak from the hepatic fossa. It wasrecommended in consultation with Dr. [**First Name (STitle) **] and Dr.[**Last Name (STitle) **] toproceed with a percutaneous drainage of fluid collection byinterventional radiology on [**4-1**]. Postoperative hematocritshowed a change from 33 to 22. The patient was tachycardiactransfused two units of blood and returned to the operating roomfor exploration on [**4-2**]. Patient was kept in the ICU intubated.Patient was extubated on [**4-5**]. She was subsequently transferredout of the unit. Patient was deemed stable and suitable fordischarge on [**4-8**]. JP x 2 were removed on discharge.Medications on Admission:Singulair 10'Admission Date: [**2189-9-4**] Discharge Date: [**2189-9-8**]Date of Birth: [**2118-4-3**] Sex: FService: MED
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 281**]Chief Complaint:S/p L mainstem bronchus stent removalMajor Surgical or Invasive Procedure:Bronchoscopy with stent removalIntubation and extubationHistory of Present Illness:71yo F with a history of stage IIIa non-small lung [**Hospital 4699**]transferred to the MICU after rigid bronch for observation. Thepatient was diagnosed with
lung cancer
DISEASE
in 4/00 and is now s/pRUL lobectomy carboplatin tx and radiation tx. Since then shehas had multiple bronchoscopies including placement of a stentinto the L main bronchus in [**4-1**]. On [**8-20**] she had abronchoscopy which revealed significant narrowing of L mainbronchus with formation of granulation tissue. She underwentrigid bronchoscopy on the day of admission ([**2189-9-4**]) showingalmost 95 percent obstruction of the left mainstem bronchus. Shewas treated with stent removal debridement of a large amount ofgranulation tissue and argon laser coagulation.The patient was felt to be at risk for airway collapse and
bleeding
DISEASE
after the procedure and was not extubated. She wastransferred to the MICU from the PACU for further monitoring andevaluation.Past Medical History:1. Right upper lobe lung cancer (
adenocarcinoma
DISEASE
stage III). In[**4-/2185**] right wedge biopsy -
adenocarcinoma
DISEASE
. In 04/00 rightupper lobe lobectomy. Positive hilar/paratracheal nodeinvolvement.2.
Hypothyroid
DISEASE
.3.
Hyperlipidemia
DISEASE
4. Right arm surgery (Admission Date: [**2186-9-29**] Discharge Date: [**2186-10-13**]Date of Birth: [**2133-2-21**] Sex: FService:CHIEF COMPLAINT: Metastatic
thyroid cancer
DISEASE
to the lungs.HISTORY OF THE PRESENT ILLNESS: The patient is a 53-year-oldfemale with a history of
hypertension
DISEASE
non-insulin-dependent
diabetes mellitus
DISEASE
and a long history of
multinodular goiter
DISEASE
which has doubled in size recently. The patient was admittedon [**8-/2186**] and found to have D-differential papillary
carcinoma
DISEASE
on fine-needle aspiration. The patient was alsofound to have multiple pulmonary nodules on chest CT andchest x-ray at that time and the patient was admitted on[**2186-9-13**] with
shortness of breath
DISEASE
and aspirate of rightlower lobe nodule at that time revealed malignant cells. Thepatient was scheduled for total thyroidectomy with thesurgery team on [**9-29**] with plan to pursue adjuvantchemotherapy and XRT to the surgical bed. The patient was toreceive carboplatinum and Taxol as the chemotherapeuticregimen. The patient had a CAT scan at that time whichrevealed multiple pulmonary nodules. The patient presentedwith progressive
shortness of breath nonproductive cough
DISEASE
right sided chest discomfort. Postoperatively the patienthad increased
hypoxia
DISEASE
. The patient was found to have smallPEs on CT angiogram. The patient was heparinized andcoumadinized at that time. The patient was started ondecadron prechemotherapy and the course was complicated bypossible
pneumonia
DISEASE
on chest x-ray. There was no complaintsof
chest pain nausea vomiting abdominal pain
DISEASE
or
pleuritic
DISEASE
chest pain
DISEASE
that the patient recalls.PAST MEDICAL HISTORY:1.
Thyroid cancer
DISEASE
tissue biopsy awaiting diagnosis with
pulmonary metastasis
DISEASE
diagnosed by FMA as D-differentiated
papillary carcinoma
DISEASE
versus
medullary carcinoma
DISEASE
.2. Multinodular
goiter
DISEASE
times 34 years.3. Hypertension.4. Non-insulin-dependent
diabetes mellitus
DISEASE
on oralhypoglycemics.MEDICATIONS ON ADMISSION:1. Glucophage b.i.d.2. Uniretic 25/15 q.d.ALLERGIES: No known
drug allergies
DISEASE
.MEDICATIONS ON TRANSFER: Medications upon transfer to themedicine service were as follows:1. Regular insulin sliding scale.2. Tums 500 mg t.i.d.3. Albuterol nebs q.6 hours p.r.n.4. Levofloxacin 500 mg q.d.5. Levoxyl 100 mg q.d.6. Lopressor 50 mg b.i.d.7. ....................20 mg PO q.d.8. Protonix 40 mg q.d.9. Oxycodone p.r.n.10. Morphine IV q.4h. to
q.6.p.r.n
DISEASE
.11. Albuterol and Atrovent MDIs.SOCIAL HISTORY: The patient lives with her daughter. T wasborn in [**Location (un) 4708**]. The patient was a day care provider andhas three children. The patient denies tobacco or alcoholuse.FAMILY HISTORY:1.
Hypertension
DISEASE
.2. Admission Date: [**2193-11-18**] Discharge Date: [**2193-11-26**]Date of Birth: [**2154-4-7**] Sex: MService: MEDICINE
Allergies
DISEASE
:OxycodoneAttending:[**Male First Name (un) 4578**]Chief Complaint:.Right patellar
fracture
DISEASE
.Major Surgical or Invasive Procedure:.1. open reduction internal fixation for right patellar
fracture
DISEASE
.2. Cardiac catheterization.History of Present Illness:CC:[**CC Contact Info 4714**].HPI: 39 yo M w h/o
G6PD deficiency DM2
DISEASE
s/p ORIF (intubatedduring procedure) for R patella fx. Post-surgical coursecomplicated by 02 desat to the 80's on
RA
DISEASE
and post-op
pain
DISEASE
. Pt.required 6L FM 02 to incr. sats to the 90's. Additionally EKGshowed diffuse ST
depressions
DISEASE
and TWI. Pt. was transferred tothe [**Hospital Unit Name 153**] for observation and management of
hypoxia
DISEASE
. The pt. hadan epidural placed for
pain
DISEASE
control which has now been d/c'd. Heis now transferred to [**Hospital Unit Name 196**] for further workup of EKG changes andpossible cardiac catheterization. He denies any
chest pain
DISEASE
orSOB during this hospitalization..ROS: Pt. denies
headaches
DISEASE
SOB CP(although he does describe afew episodes of
chest pain
DISEASE
with excercise and at rest in thepast).
Denies N/V
DISEASE
denies
diarrhea
DISEASE
admits to
constipation
DISEASE
andreflux as inpatient..Past Medical History:.- OSA(newly diagnosed)- G6PD deficiency- DM 2- h/o genital
herpes
DISEASE
- R patella fx: occurred while playing basketball on [**11-8**].Underwent ORIF of R knee on [**11-18**] due to non-[**Hospital1 **].- s/p repair of R ruptured patellar tendon in [**2185**].Social History:.SOCIAL HISTORY: He is currently working as a realtor. He doesnot smoke never smoked in the past but does drink alcoholsocially..Family History:.FAMILY HISTORY:No fam hx of CAD or
cancer
DISEASE
..Physical Exam:.PHYSICAL
EXAM
DISEASE
:Vitals: 140/84 68 100%RA FS 153Gen: NAD AAOx3HEENT: EOMI PERRLCardio: distant heart sound normal S1/S2 no murmurs.Resp: CTA bilat. no wheezes cracklesAbd:
NT/ND
DISEASE
BS normoactiveExt: R knee immobilizer in place 1Admission Date: [**2109-8-7**] Discharge Date: [**2109-8-17**]Date of Birth: [**2053-7-14**] Sex: FService: DR.[**Last Name (STitle) **][**First Name3 (LF) 275**] E. 02-248Dictated By:[**Dictator Info **]MEDQUIST36D: [**2109-8-17**] 13:51T: [**2109-8-22**] 08:45JOB#: [**Job Number 4718**]Admission Date: [**2109-8-7**] Discharge Date: [**2109-8-17**]Date of Birth: [**2053-7-14**] Sex: FService: CARDIOTHORACICHISTORY OF PRESENT ILLNESS: This is a 56 year-old woman whohad a preop electrocardiogram for a spinal surgery that wasnotable for ischemic changes. She underwent a stressechocardiogram on [**7-5**] that demonstrated inferior wallnear akinesis. On [**8-2**] she underwent a cardiaccatheterization that revealed a 50% occlusion of her LAD anda 90% occlusion of her left circumflex as well as a 100%occlusion of the RCA. She had an echocardiogram thatdemonstrated an ejection fraction of approximately 40%. Thedecision was made that the patient should undergo a coronaryartery bypass surgery.MEDICATIONS ON ADMISSION: Rocaltrol 0.625 mg q.d.Nephrocaps 1 mg po q.d. Lipitor 10 mg po q.d. Provera 2.5mg po q.d. Premarin 0.625 mg q.d. Norvasc 5 mg po b.i.d.Gabapentin 100 mg po t.i.d. and Dilaudid 4 mg po q.i.d.PAST MEDICAL HISTORY: 1. Stable
angina
DISEASE
. 2. Type 2 insulindependent
diabetes mellitus
DISEASE
on hemodialysis and
neuropathy
DISEASE
.3. Hypertension. 4. Hypercholesterolemia. 5.
Degenerative joint disease
DISEASE
at the L4-L5 interspace.HOSPITAL COURSE: The patient was admitted on [**2109-8-7**] to the [**Hospital Unit Name 196**] Service. On [**8-8**] the patientunderwent an uncomplicated coronary artery bypass graft timesthree with the left internal mammary coronary artery to theleft anterior descending coronary artery saphenous veingraft to the obtuse marginal 1 and the saphenous vein graftto the right posterior descending coronary artery. Thepatient tolerated the procedure well and was transported tothe CSRU intubated and in stable condition.Immediately postoperative the patient was able to answerquestions and follow commands. She was weaned off of theventilator and extubated. Her chest tube was notable for asmall air leak initially. On postoperative day one she wasstarted on Lopressor as well as aspirin. She was weaned fromthe Levophed and started on a renal diet. Her pleural chesttube was left in place and the Renal Service was consultedfor management of her dialysis. At that time she was beingatrially paced at 80 over a normal sinus rhythm at 60. HerLevophed was discontinued and she was weaned from theMilrinone. She underwent hemodialysis. On postoperative daytwo the patient's heart rate was in the 80s with sinus rhythmwith a blood pressure of 118/67. Her pacemaker wassubsequently turned off as it was competing with herunderlying rhythm. She was stable and was transferred to thefloor.On the floor the [**Hospital 228**] hospital course was uneventful.She remained afebrile with good
pain
DISEASE
control and maintaininga sinus rhythm. She experienced some
nausea
DISEASE
and some
emesis
DISEASE
associated with her potassium supplements. Her blood sugarswere well controlled but she was somewhat anorexic. Shealso began complaining of some mild mid
epigastric tenderness
DISEASE
on postoperative day five associated with some
nausea
DISEASE
. Shewas also noted to have an elevated white blood cell count of24000 as well as mildly elevated transaminase and alkalinephosphatase levels. She underwent a KUB which was notablefor her colon being full of stool. She also had a rightupper quadrant ultrasound that was negative for biliarydisease processes. She was begun on a regimen of Cascara andMilk of Magnesia with subsequent large
bowel movements
DISEASE
withrelief of her
abdominal pain
DISEASE
. She was noted to have asomewhat swollen right lower extremity which was the site ofthe saphenous vein graft and concern for a possible deep
venous thrombosis
DISEASE
as the etiology of the increased whiteblood cell count prompted a venous duplex ultrasound. Theresult of this study was negative for deep
venous thrombosis
DISEASE
.By postoperative day nine the patient had remained afebrileand her white count had steadily declined to 17400. Thepatient was subsequently discharged with instructions toreturn to clinic and/or the Emergency Department if sheshould become ill.PHYSICAL EXAMINATION ON DISCHARGE: The patient was afebrilewith stable vital signs. She was in no acute distress alertand oriented. Her lungs were clear. Her sternum was stable.Her incision was clean dry and intact. Her heart had aregular rate and rhythm and a 2/6 systolic ejection murmur atthe base. Her belly was soft nontender nondistended. Herextremities were warm and well profused and her incision wasclean dry and intact. She had a small amount of
swelling
DISEASE
onher right lower extremity.DISCHARGE MEDICATIONS: Lopressor 12.5 mg po b.i.d. Percocetone to two tablets po q 3 to 4 hours prn
pain
DISEASE
Colace 100 mgpo b.i.d. ECASA 81 mg po q.d. Ibuprofen 400 mg po t.i.d.Gabapentin 100 mg po t.i.d. Amiodarone 400 mg po b.i.d.times seven days and then 400 mg po q.d. Nephrocaps onetablet q.d. Premarin 0.625 mg po q.d. Rocaltrol 0.5 mg poq.d. Provera 2.5 mg po q.d.The patient was subsequently discharged in stable conditionwith instructions to return to the clinic or the EmergencyDepartment if she was feeling ill and to follow up with Dr.[**Last Name (STitle) 1537**] in one weeks time as well as her primary care physician[**Last Name (NamePattern4) **]. [**First Name (STitle) **] in one to two weeks time. She is sent home withplans for [**Location (un) 86**] VNA to come in and check on her for homesafety and cardiopulmonary evaluation. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**] M.D. [**MD Number(1) 1540**]Dictated By:[**Last Name (NamePattern1) 3801**]MEDQUIST36D: [**2109-8-17**] 14:19T: [**2109-8-22**] 08:46JOB#: [**Job Number 4719**]Admission Date: [**2109-9-27**] Discharge Date: [**2109-10-25**]Date of Birth: [**2053-7-14**] Sex: FService: Cardiothoracic SurgeryHISTORY OF PRESENT ILLNESS: This is a 56-year-old woman with
non-insulin
DISEASE
dependent
diabetes mellitus
DISEASE
coronary arterydisease status post three vessel coronary artery bypassgraft in [**8-3**] end stage
renal disease
DISEASE
on hemodialysisrushed to the [**Hospital1 69**] EmergencyRoom with
fever
DISEASE
for three days
shortness of breath
DISEASE
and rightsided
chest pain
DISEASE
. She has been meanwhile at home receivingvisiting nurse care. She states the
fever
DISEASE
at home was ashigh as 101.4 degrees. She was previously admitted to CTsurgery service for median sternotomy wound drainage whichrequired IV antibiotics and wound debridement. At home shedenies any productive cough wheezing or wound drainage. Thesymptoms were first noticed by the patient two days ago andhave worsened over the past several days.PAST MEDICAL HISTORY: As described in history and physical.MEDICATIONS: On admission Aspirin 81 mg po q day Premarin0.625 mg po q day Norvasc 5 mg po bid TrazodoneHydroxyprogesterone Neurontin 300 mg po bid Ultram 50 mg poq day Lipitor 10 mg po q day Pravachol 0.25 mg po q dayLopressor 12.5 mg po bid.ALLERGIES: No
allergies
DISEASE
.PAST SURGICAL HISTORY: Status post CABG times three on[**2109-8-8**].PHYSICAL EXAMINATION: On admission T max 101.5 bloodpressure 106/70 pulse 88 respirations 16 FAO2 90% on fiveliters. In general alert and oriented times threeconversant pulmonary clear to auscultation left decreasedbreath sounds at the right base. CV regular rate andrhythm. Chest wall sternotomy wound the bottom half of themidline sternotomy incision is opened with fibrinous exudateand 0 drainage. There is a click appreciated when thepatient coughs. Abdomen soft nontender non distended.Right saphenectomy site small area of
erythema
DISEASE
and a largeamount of scab. Both feet are warm. There is
trace edema
DISEASE
inthe right lower extremity.Pertinent studies: Chest x-ray bilateral
pleural effusion
DISEASE
no evidence of
CHF effusion
DISEASE
is greater on the right side vsthe left. Chest no
pulmonary embolism
DISEASE
no infiltrate orconsolidation some modest right effusion with right lowerlobe atelectasis small left effusion small amount of fluidin the anterior mediastinum no
pneumomediastinum
DISEASE
.Labs CBC with white count 14.0 hematocrit 27.2 plateletcount 330000 differential of 95% neutrophils 0% bands.Chemistries sodium 135 potassium 5.2 chloride 93 CO2 28BUN 54 creatinine 6.7 glucose 264.HOSPITAL COURSE: The night of admission a thoracentesis wasperformed in the right posterior thorax. Approximately 500cc of fluid was removed. Also on the night of admission thesaphenectomy wound was sharply debrided the
bleeding
DISEASE
tissueimpacted with wet to dry dressing and normal saline and thesternal wound was sharply debrided. The granulation tissuewas packed with wet to dry dressings and normal saline. Thepatient was empirically started on Piperacillin andVancomycin. Plastic surgery was consulted they recommendedconservative management as was being performed by generalsurgery. The patient was also seen by the renal service whomanaged the patient's dialysis and electrolyte managementduring the hospitalization. PICC line was placed inanticipation of a long course of IV antibiotics. On [**9-30**] aVAC dressing was first placed in the wound. The patient wasdoing well on intravenous antibiotics and VAC dressingchanges.The [**Hospital 228**] hospital course faltered when at hemodialysisincreased venous pressures were noticed on [**10-1**]. On [**10-2**]fistulogram revealed a clotted
fistula
DISEASE
and the patient wasunable to receive her normal dialysis on [**2109-10-3**]. Transplantsurgery saw the patient and scheduled her for revision.During the interim Quinton catheter was placed in thepatient's right groin for dialysis. On the evening of[**2109-10-4**] the patient fell getting out of bed. When the houseofficer arrived the patient was confused in bed and somewhatdifficult to arouse. CT scan of the head performed on anemergent basis demonstrated no intracranial pathology.Initially the skull was intact. The next morning the patientwas difficult to arouse and her labs reflected the fact thatshe had not been dialyzed in several days with a rising BUNcreatinine and potassium. The patient was given Kayexalatefor the rising potassium. A repeat CT scan of the head wassimilar to the previous CT scan in that there was no evidenceof intracranial pathology. At this point the patient had anepisode of
bradycardia
DISEASE
with wide QRS complexes. She lostconsciousness. After receiving an amp of D50 insulin andCalcium Gluconate the patient was transferred to theIntensive Care Unit. At this point her hematocrit was foundto be 13. The patient vomited a large amount of guaiacpositive material.In the Intensive Care Unit the patient was transfused fourunits of packed red cells and 4 units of FFP. The patientwas intubated and an NG tube was placed. Large amount ofbloody material was aspirated from the stomach. GI servicewas consulted for an emergent EGD which revealed an enormousamount of clot protruding from the pylorus and bright redblood was seeping around it. The gastroduodenal artery wasvisualized in the posterior wall of the duodenum. Thepatient was given blood and FFP to maintain hematocrit and tocombat an ongoing
coagulopathy
DISEASE
. On [**10-4**] the patient went tothe interventional radiology suite and had anangioembolization of the gastroduodenal artery. At thispoint patient was placed on Protonix and started on a courseof Amoxicillin and Clarithromycin in addition to thePiperacillin and Vancomycin.The patient received her dialysis in the ICU beginning on[**2109-10-5**]. During this course in the Intensive Care Unit thepatient remained intubated and was repeatedly transfused tokeep her hematocrit above 30. By [**2109-10-7**] the patient'smechanics were good enough to begin a wean from theventilator and by [**10-18**] she was extubated. By [**10-11**] thepatient was transferred to the patient care floor. Thepatient continued to do well on the floor the VAC dressingchanges to the sternum were continued and the size of thesternal wound had decreased with time. Additionally thesaphenectomy sites were cared for with wet to dry dressingswhich were changed over to santyl dressings twice a day.Both wounds were intermittently debrided to reveal viabletissue.On [**2109-10-15**] the transplant surgery service deemed the patientan operable candidate and brought her to the operating roomfor fistular revision. Please see previously dictatedoperative note for more details.After the
fistula
DISEASE
revision the patient was able to use her
fistula
DISEASE
for hemodialysis and the Quinton catheter wasremoved. The VAC dressing changes continued. The [**Hospital 228**]hospital course was complicated further by a brief episode ofC.
difficile colitis
DISEASE
. For this the patient was treated withFlagyl for 10 days and remained on Piperacillin andVancomycin. By [**2109-10-26**] the patient was accepted to[**Hospital3 **]. At this point patient's wounds were stableshe had a PICC line in place was tolerating po and was readyto go to rehabilitation.CONDITION ON DISCHARGE: Stable.DISCHARGE DISPOSITION: To rehab.DISCHARGE MEDICATIONS: Regular insulin sliding scale asfollows: Glucose 150-200 gets 2 units 201-250 gets 4 units
251-300 gets 6 units 301-150 8 units Epogen 14000 units qhemodialysis Vitamin A D Zinc ointment to affected areatid Vancomycin 500 mg IV after hemodialysis times 6 weeksNeurontin 500 mg po bid Norvasc 5 mg po bid Trazodone 100mg po q h.s. Lopressor 25 mg po bid Lipitor 10 mg po qh.s. Piperacillin 3 gm IV q 8 hours for 6 more weeksCaptopril 12.5 mg po q 8 hours Protonix 40 mg po q dayMiconazole powder applied to affected areas prn MorphineSulfate 2 mg IV before dressing changes.DISCHARGE DIAGNOSIS:1. Sternal wound
infection
DISEASE
.2. Infection of saphenectomy site.3.
Gastrointestinal bleed
DISEASE
status post embolization.4. C.
difficile colitis
DISEASE
. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**] M.D. [**MD Number(1) 1540**]Dictated By:[**Last Name (NamePattern4) 4722**]MEDQUIST36D: [**2109-10-25**] 19:17T: [**2109-10-25**] 19:31JOB#: [**Job Number 4723**]Admission Date: [**2168-8-3**] Discharge Date: [**2168-8-8**]Date of Birth: [**2132-1-31**] Sex: FService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2969**]Chief Complaint:
Myasthenia
DISEASE
[**Last Name (un) 2902**] in the post-partem periodMajor Surgical or Invasive Procedure:Trans-sternal thymectomy with mediastinal lymphadenectomyHistory of Present Illness:Ms. [**Known lastname 4735**] is a 36 yo F who in the early postpartum perioddeveloped a
weakness syndrome
DISEASE
which eventually was diagnosed as
myasthenia
DISEASE
[**Last Name (un) 2902**] based onstandard serologies and a Tensilon test. She unfortunately hasbeen refractory to medical management. A CT scan showed no
thymoma
DISEASE
but fullness of the thymus. After consultation with herneurologist we recommended thymectomy as an adjunct to hermanagement.Past Medical History:1. G1P1 with delivery of healthy baby girl [**2167-9-17**]2. Status post tonsillectomySocial History:She is married with one child. Works [**Street Address(1) 4736**] Bank as aportfolio manager. No history of tobacco alcohol or illicitdrug use.Family History:No family history of neurologic or other
autoimmune disease
DISEASE
.Physical Exam:At time of discharge:A&O X 3 NADTachycardic no murmur appreciatedLungs CTAB no w/r/rMidline sternotomy dressing c/d/iAdmission Date: [**2152-3-23**] Discharge Date: [**2152-3-25**]Date of Birth: [**2079-4-19**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**Last Name (NamePattern1) 495**]Chief Complaint:
Shortness of Breath
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Patient is 72 year Spanish speaking male with PMHx of
Parkinson's Disease
DISEASE
who presents to the ED for complaints of
shortness of breath
DISEASE
. Per patient daughter he was at his baselinehealth until night prior to admission when patient described
shortness of breath and sensation
DISEASE
that his airways were blocked.Patient was seen at [**Hospital1 112**] a few weeks ago for similar symptoms.Per daughter etiology of
shortness of breath
DISEASE
was not identifiedand thought breathing difficulty could be due to
anxiety
DISEASE
.Patient denies any
chest pain
DISEASE
or
diaphoresis
DISEASE
and is symptoms donot seem to coorelate with any medications. He has noticed nochange in his speech or any trouble with swallowing or eatingand drinking foods.During this episode of
shortness of breath
DISEASE
at home patientseemed anxious and paramedics were called. While they werepresenthe had brief unresponsiveness and was found to be in atrial
fibrillation
DISEASE
. A nasal trumpet was placed with return ofresponsiveness and of sinus rhythm. He was brought to [**Hospital1 18**]. Onarrival to ICU patient comfortable denies any shortness ofbreath. He has a nasal trumpet in place. His O2Sat remains above90% on room air but appears to drop when patient falls asleep.Patient denies any
swelling
DISEASE
of his throat or airway he justfeels congested in his nasal passages..ROS: Patient denies any CP HA n/v
fevers chills cough
DISEASE
abdominal pain
DISEASE
. Patient is urinating normally and besides
constipation
DISEASE
has normal
bowel movements
DISEASE
. His Parkinson's hasgotten worse over the last year but no acute worsening over thepast few months.Past Medical History:
Parkinson's disease
DISEASE
diagnosed at age 66 followed by Dr.[**Last Name (STitle) 4742**]at [**Hospital1 2025**]PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4743**] at [**Hospital1 112**]Social History:Lives with wife and sister-in-law who have been limiting hisactivities more recently though he did go out of the house oncelast week by himself. Able to do laundry for example b/c didit last week but not allowed by his wife (per daughter). Notobacco EtOH drug use.Family History:noncontributoryPhysical Exam:T 98.1 BP 127/74 HR 77 O2Sat 93%-94% on
RA
DISEASE
Gen: NADHeent: PERRL EOMI OP clear no
pharyngeal swelling
DISEASE
nasaltrumpet in place MM
dry
DISEASE
.Neck: supple no LADLungs: CTA B/LCardiac: RRR S1/S2 no murmursAbd: soft NTND NABSExt: FROM no
edema
DISEASE
Neuro: AAOx3 patient with resting
tremors
DISEASE
of UE and LE b/lnormal reflexes sensory grossly intactPertinent Results:[**2152-3-23**] BLOOD WBC-12.1* RBC-4.53* Hgb-14.1 Hct-40.9 MCV-90MCH-31.0 MCHC-34.4 RDW-13.7 Plt Ct-258[**2152-3-23**] BLOOD Neuts-86.4* Bands-0 Lymphs-9.7* Monos-3.1 Eos-0.6Baso-0.2[**2152-3-23**] BLOOD PT-12.1 PTT-24.7 INR(PT)-1.0[**2152-3-23**] BLOOD Glucose-130* UreaN-12 Creat-0.9 Na-136 K-4.0Cl-97 HCO3-25 AnGap-18[**2152-3-23**] BLOOD CK(CPK)-103[**2152-3-23**] BLOOD cTropnT-Admission Date: [**2125-8-31**] Discharge Date: [**2125-9-2**]Date of Birth: [**2059-7-11**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 552**]Chief Complaint:BRBPR after colonoscopy with polypectomyMajor Surgical or Invasive Procedure:ColonoscopyHistory of Present Illness:66 y/o M with PMHx of Atrial Fib who went for colonoscopy on[**8-29**] after holding coumadin for 3 days prior to procedure andunderwent three polypectomies-proximal transverse distaltransverse and cecum. On [**2125-8-30**] pt noted some crampy lower
abdominal pain
DISEASE
when he awoke and noticed a small amount of bloodin BMs. Pt went to work but was concerned with the continuedBRBPR approx 4 episodes. Pt reportes feeling dizzy when he sawthe blood in the toilet but denied any
syncope
DISEASE
or
presyncope
DISEASE
.Pt initially presented to [**Hospital Ward Name **] thinking it was the EDand medical emergency was called. Pt was found with blood onseat of pants & e/o
incontinence
DISEASE
..Pt was transferred directly to the ED where initial VS 96.7 HR90 BP 117/70 RR 16 and Sats 97% on
RA
DISEASE
. Hct was down from 54 in[**3-17**] to 39.1. Pt received 2L of NS but did not receive anyblood products overnight and am HCT was down at 29.7. Pt had anepisode of BRBPR on the floor and became tachy to 140s.Decision was made for transfer to ICU and per GI recs pt hadalready begun taking Golytely prep..On arrival to ICU pt was anxious but denying any CP/SOB/Abd
pain
DISEASE
or
nausea
DISEASE
. He had already taken approx half of thegolytely prep and was complaining of
chills
DISEASE
..ROS: The patient denies any
fevers chills nausea vomiting
DISEASE
diarrhea constipation hematemesis shortness of breath cough
DISEASE
urinary frequency urgency dysuria
DISEASE
.Past Medical History:
Atrial fibrillation
DISEASE
anticoagulated but pt has been holdingcoumadin for approx 3 days prior to colonoscopy not restarted
Gout
DISEASE
Hyperlipidemia
DISEASE
Hypertension
DISEASE
Social History:patient lives in [**Location 745**]. He is married with 2 children. He isan active smoker and has prior 50-pack-year cigarette historyand has never used IV drugs. He drinks alcohol rarely only onsocial occasions.Family History:non-contributoryPhysical Exam:Vitals: T- 96.7 BP 111/67 HR 90 RR 18 Sats 100% on
RA
DISEASE
GEN: Well-appearing well-nourished no acute distressHEENT: EOMI PERRL sclera anicteric no
epistaxis
DISEASE
orrhinorrhea MMM OP ClearNECK: No JVD carotid pulses brisk no
bruits
DISEASE
no cervical
lymphadenopathy
DISEASE
trachea midlineCOR: RRR no M/G/R normal S1 S2PULM: Lungs CTAB no apprec W/R/RABD: Soft NT ND Admission Date: [**2178-1-18**] Discharge Date: [**2178-1-23**]Date of Birth: [**2114-2-8**] Sex: MService: [**Location (un) 259**]HISTORY OF PRESENT ILLNESS: This is a 63-year-old male withhistory of multiple medical problems who was recentlyadmitted to the [**Hospital6 256**] from[**2178-11-26**] to [**2177-12-5**] with
projectile vomiting
DISEASE
andhematocrit of 13.He had negative
hemolysis
DISEASE
workup and negative EGD times twoand a colonoscopy times one. Found to have a right upper andright lower extremity deep
venous thrombosis
DISEASE
. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**]filter was placed and he was transferred to [**Hospital **] Rehaband went home in late 01/[**2177**].He received seven units of packed red blood cells sevenunits of fresh frozen plasma and one unit during previoushospitalization and two units of packed red blood cells whilehe was at [**Hospital1 **]. He had no
nausea vomiting diarrhea
DISEASE
abdominal pain
DISEASE
bright red blood per rectum.Ten days ago his Coumadin and aspirin were continued forplanned EGD and colonoscopy with good prep. On [**2178-1-15**] hehad an EGD
polyp
DISEASE
removed from the esophagus which wasnegative. His colonoscopy revealed two polyps which were
adenomatous
DISEASE
without any complications.Then on [**2178-1-17**] at about 10 p.m. he developed severebilateral lower
abdominal pain
DISEASE
and bright red blood perrectum times three at home and times two in the EmergencyRoom. He denies
nausea
DISEASE
but vomited once after GoLYTELY inthe Emergency Room. He had no change in
shortness of breath
DISEASE
.
Denies chest pain fever chills cough wheezing dysuria
DISEASE
.PAST MEDICAL HISTORY:1. Chronic
obstructive pulmonary disease
DISEASE
.2. Lung cancer status post right pneumonectomy in [**1-/2175**]complicated by the PA laceration.3. Prostate cancer status post prostatectomy six years agobut has had recently increasing prostate specific antigen andwas scheduled for an outpatient bone scan.4. History of perioperative
pulmonary embolism
DISEASE
. Had[**Location (un) 260**] filter placed.5.
Atrial fibrillation
DISEASE
sinus rhythm with Amiodarone.6.
Hypertension
DISEASE
but has recently been
hypotensive
DISEASE
.7. Diabetes type 2 complicated by
neuropathy
DISEASE
.8.
Gastroesophageal reflux disease
DISEASE
and negative history for
peptic ulcer disease
DISEASE
.9. Obstructive
sleep apnea
DISEASE
but does not tolerate continuouspositive air pressure.10.
Hypercholesterolemia
DISEASE
.11. Vitamin B12 deficiency.12. History of transient
ischemic attacks
DISEASE
.13.
Cataracts
DISEASE
.14. Trach placement for suctioning and oxygen requirement in07/[**2176**].ALLERGIES:1. Doxepin.2. Levofloxacin.3. OxyContin.MEDICATIONS ON ADMISSION:1. Potassium chloride.2. Colchicine.3. Protonix.4. Lasix.5. Paxil.6. Multivitamin.7. Colace.8. Senna.9. Roxanol.10. Tylenol with Codeine.11. Combivent.12. Amiodarone.13. Neurontin.14. Ferrous Sulfate.15. Vitamin B12.16. Glyburide.17. Lipitor.18. Scopolamine patch.19. Advair.20. Combivent nebulizer.FAMILY HISTORY: Mother with
coronary artery disease
DISEASE
.SOCIAL HISTORY: Lives with his wife. Is retired. Doestobacco 160-pack-year history but quit in [**2174**]. Quitalcohol in [**2173**]. No drug use.PHYSICAL EXAMINATION ON ADMISSION: Vitals: Temperature98.4 pulse 94 blood pressure 100/65 respiratory rate 18sat 96% on room air. In general he is well developed wellnourished maleAdmission Date: [**2111-8-4**] Discharge Date: [**2111-8-9**]Service: SURGERY
Allergies
DISEASE
:Penicillins / LyricaAttending:[**First Name3 (LF) 4748**]Chief Complaint:Right lower extremity rest
pain
DISEASE
with
non-healing
DISEASE
right toe
ulcer
DISEASE
Major Surgical or Invasive Procedure:Right femoro-peroneal bypass graft with lesser saphenous veingraftHistory of Present Illness:This patient is an 85 year old male with a history of severe
coronary artery disease
DISEASE
s/p
myocardial infarction
DISEASE
congestive
heart failure hypertension
DISEASE
who presents with chronitunremitting right lower extremity rest
pain
DISEASE
and a non-healingright toe
ulcer
DISEASE
. The patient received an extensive coronarywork-up prior to presentation and was felt to be a pooroperative candidate given his other co-morbidities. This poorcandidate status was discussed at length with the patient andhis family who remained quite insistent that despite the highrisks we procede with a limb-saving interventionPast Medical History:CADMI CHFHTNhypercholestremiaDUJd of rt. hiphx TISs/p leftCEA [**2094**]'sBPH s/p turn-now w frequency/nocturiaSocial History:Remote history of smoking quit 40 years ago social ETOH use.Physical Exam:Awake and alert NADRRR w/ SEM at baseCrackles at lung bases on auscultation bilaterallyAbdomen soft obese non-tenderPulse exam: DP/PT dopplerable bilaterallyBrief Hospital Course:The patient was admitted to the hospital and started on IVantibiotics to treat his non-healing
ulcer
DISEASE
. Cultures were takenand ultimately grew out gram-positive cocci and gram-negativerods. He was taken to the operating room on [**8-6**] for a rightfemoro-peroneal bypass graft with lesser saphenous vein. Thepatient initially tolerated this procedure well and was taken tothe vascular surgery ICU for recovery. On the morning ofpost-operative day #2 the patient began to complain of chest
pain
DISEASE
and was found to have a systolic blood pressure of 85 withelevated pulmonary artery pressures of 60/30. This picture wasconcerning for an active coronary event. The patient wasimmediately transferred to the cardiovascular surgery ICU forfurther monitoring and treatment. An electrocardiogram showednew lateral precordial ST-segment elevation. Troponins werechecked and were found to be rising to 0.67. At 2:30am onpost-operative day #3 the patient was found to be tachypnic andtachcardic. Lasix was given emperically however soon after thepatient became unresponsive and
asystolic
DISEASE
. ACLS protocol wasinitiated and the patient was coded for 30 minutes withoutreturn of cardiac function. The patient was pronounced deceasedat 3:57am.Medications on Admission:lasix 80mgm qamlasix 40mgm qpmplavix 75mgm'kcl20meqAdmission Date: [**2129-1-5**] Discharge Date: [**2129-1-12**]Service: MEDICINE
Allergies
DISEASE
:Ciprofloxacin / Cisapride / Metoclopramide / BactrimAttending:[**First Name3 (LF) 3984**]Chief Complaint:Respiratory DistressMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:[**Age over 90 **] yo M w/ multiple medical problems (see below) who presentsfrom [**Hospital 100**] Rehab hypoxic and
febrile
DISEASE
with CP and bilatinfiltrates requiring intubation in the ED. At baseline per theson Mr. [**Known lastname 4749**] is a wheelchair bound russian speaking alertand lively gentleman. He last saw his father on [**Name2 (NI) **] [**2129-1-2**]and he was at his baseline. Per the records from the rehab thepatient was well up until the day of admission when he vomitteda large ammount of
bilious vomit
DISEASE
x2 and appeared to be shakingand cyanotic. Vitals at the time were T 104 (rectal) BP 120/60O2 89%on
RA
DISEASE
. Aspiration pna was suspected and he was tx to [**Hospital1 18**]for further care..In the ED the patient was found to be
febrile
DISEASE
to 103 butotherwise hemodynamically stable. Patient then experiencedoxygen desaturation to 70's and was intubated. Patient was foundto have large mucous plugs on suctioning consistent withaspiration. Dopamine was started for low BP while on vent.Past Medical History:CRI (b/l 1.3-1.9 1.5 yrs ago) (Cr 2.3 on [**12-28**])Afib/CHF s/p Pacemaker EF 60% with 1Admission Date: [**2189-4-13**] Discharge Date: [**2189-4-27**]Date of Birth: [**2119-2-12**] Sex: FService: MEDICINE
Allergies
DISEASE
:Penicillins / Shellfish Derived / SimvastatinAttending:[**First Name3 (LF) 4760**]Chief Complaint:SOB increasing
lower extremity edema
DISEASE
Major Surgical or Invasive Procedure:IVC filter placement [**4-17**]10U prbc transfusionMidline placement [**2189-4-27**]History of Present Illness:70 year old female with h/o
RA
DISEASE
previously on humera and mtx whowas discharged on [**2189-4-11**] when she presented with R shoulder
pain
DISEASE
. Her joint was tapped and it demonstrated an inflammatoryjoint fluid c/w with
RA
DISEASE
and negative for
septic arthritis
DISEASE
. Shewas discharged on ibuprofen prn. Upon return home 3 days priorto presentation she felt very well but one day later noticed thegradual onset of
dyspnea
DISEASE
on exertion. She also had episodes ofchest twinges overnight which resolved within minutes. Admission Date: [**2194-11-2**] Discharge Date: [**2194-11-11**]Date of Birth: [**2115-11-26**] Sex: FService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 4765**]Chief Complaint:STEMI and possible Aortic DissectionMajor Surgical or Invasive Procedure:Cardiac catheterization with placement of 2 bare-metal stents toPDAHistory of Present Illness:78 yo F w/ s/p CABG in [**2178**] w/ 2 vision stents who initiallypresented to [**Hospital3 **] on [**11-1**] by ambulance withgeneralized
weakness
DISEASE
worse on the left side. EMTs noted slightfacial droop on the L side w/ weakend L sided grip and left armdrifting. CT Scan showed no evidence of an acute process. At theOSH her TropI were 0.02 --Admission Date: [**2201-5-25**] Discharge Date: [**2201-5-30**]Date of Birth: [**2138-9-5**] Sex: MService: CSUADMISSION ILLNESS: The patient was admitted with
mitral
valve regurgitation
DISEASE
and
atrial fibrillation
DISEASE
. He is a 62-year-old patient of Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] and Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] with
mitral valve disease
DISEASE
referred for outpatientcardiac catheterization prior to valve surgery.HISTORY OF PRESENT ILLNESS: This 62-year-old man has ahistory of
mitral valve disease
DISEASE
and paroxysmal atrial
fibrillation
DISEASE
. His most recent echocardiogram is from[**2201-1-27**] where the EF was noted at greater than 60 percentwith mild
LVH
DISEASE
and a mildly
dilated left ventricular cavity
DISEASE
.There was moderate dilation of the left atrium. The mitralvalve leaflets were myxomatous and mildly thickened withmoderate-to-severe
mitral valve prolapse
DISEASE
and 2 plus mitralregurgitation. His most recent stress test was in [**2197**] anddid not reveal any objective evidence of
ischemia
DISEASE
.He denies
chest discomfort shortness of breath fatigue
DISEASE
or
dizziness
DISEASE
. In terms of his
atrial fibrillation
DISEASE
he reportsthat he has not had any episodes in several months. He isreferred not to be anticoagulated with Coumadin and is ondaily aspirin therapy along with propafenone.
Denies claudication edema orthopnea
DISEASE
PND orlightheadedness.PAST MEDICAL HISTORY:
Mitral valve disease
DISEASE
PAF history ofremote prior DCCP and also BPHAdmission Date: [**2122-12-25**] Discharge Date: [**2122-12-29**]Date of Birth: [**2067-2-2**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 3556**]Chief Complaint:
Headache malaise nausea disorientation
DISEASE
Major Surgical or Invasive Procedure:Lumbar punctureHistory of Present Illness:This is a 55 year old gentleman with chronic
hypocapnia
DISEASE
central
sleep apnea episodic hyperventilati
DISEASE
onorthostatic
hypotension
DISEASE
and
autonomic dysfunction
DISEASE
who is suspected to have a syndromerelated either to
mitochondrial disease channelopathy
DISEASE
or anuncharacterized metabolic pathway disturbance. He presented tothe ED after a particularly severe episode of his chronic
hypocapnia
DISEASE
. These episodes have been going on for eleven yearsand have been characterized by
nausea headache malaise
DISEASE
andlightheadedness. Particularly bad episodes will lead to frankdisorientation as this one did. The patient monitors hisend-tidal CO2 at home and his urinary pH. He reports thatwhen his end-tidal CO2 is low or his pH is not sufficientlyalkalemic he tends to get these episodes.The only treatment that seems to have helped his symptomsconsistently is bicarbonate replacement.On consultation with his sleep physician [**Last Name (NamePattern4) **]. [**Known firstname **] [**Last Name (NamePattern1) **] itwas decided that given his uncharacterized syndrome he wouldbe admitted to the MICU for intensive monitoring of his bloodgas and chemistries to further define the biochemical nature ofhis syndrome. This originally was to have occurred next week.He however had another episode of his hypocapneic syndromeyesterday while vacationing in [**State 108**]. He was disoriented fortwo hours. Home test of end-tidal CO2 during a
hyperventilation
DISEASE
episode was in the 20's. His wife [**Name (NI) 653**] Dr. [**First Name (STitle) **] 6 hoursprior to admission and it was decided he should fly back to[**Location (un) 86**] and present to the ED for admission to the MICU.In the ED initial vital signs T 99.7 P 94 BP 111/67 O2 97 on2L. He was nauseated but no longer disoriented. He had takenbicarbonate last about 8 hours previously. A VBG revealed7.41/25/147/16. Bicarb was on chemistries which were otherwiseunremarkable He received zofran for
nausea
DISEASE
as well as one literIVF.On presentation to MICU the patient reports his still feels hisusual symptoms of
nausea headache
DISEASE
and lightheadedness. Hedenies
fevers
DISEASE
or sick contacts. [**Name (NI) **] traveled to [**State 108**] lastweek and does report his symptoms worsen with altitude or withair travel.Past Medical History:1) Central sleep apnea2)
Coronary artery disease
DISEASE
single
vessel disease
DISEASE
on [**2116**]catheterization: two bare metal stents to the OM2 vessel3)
Hypertension
DISEASE
on antihypertensive medications x 6yrs4)
hyperlipidemia
DISEASE
5) Orthostasis postural
hypotension
DISEASE
6)
Gout
DISEASE
7) Hypogonadotropic
hypogonadism
DISEASE
8) Empty sella nl pituitary function9)
Chronic kidney disease
DISEASE
stage III baseline cr 1.1-1.310) Rapid cycling
mood disorder
DISEASE
Social History:He is married with two children. There is no history oftobacco alcohol or illicit drug use. He is a venturecapitalist and engineer.Family History:Mother died at age 72 with a
neuromuscular disorder dystonia
DISEASE
and
respiratory failure
DISEASE
. She also suffered from
hypertension
DISEASE
and
obstructive sleep apnea
DISEASE
.His father died at age 64 from
stomach cancer
DISEASE
but had also beendiagnosed with stage I
renal cell carcinoma
DISEASE
and had a
CVA
DISEASE
at age59. Multiple family members with
neurologic difficulties
DISEASE
.Physical Exam:T 99.1Admission Date: [**2194-6-18**] Discharge Date: [**2194-6-29**]Date of Birth: [**2126-4-22**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Codeine / TylenolAttending:[**First Name3 (LF) 1505**]Chief Complaint:
dyspnea
DISEASE
on exertion and
chest tightness
DISEASE
Major Surgical or Invasive Procedure:[**2194-6-23**]redo sternotomy/Aortic Valve Replacement with #23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissuevalveHistory of Present Illness:68 year old male with PMH significant for
type 2 DM HTN
DISEASE
Highcholesterol CAD and BPH who presented to an outside hospitalc/o SOb DOE and
chest tightness
DISEASE
. Pt also had leg edema-. Workup showed that pt had severe
aortic valve stenosis
DISEASE
.Past Medical History:Past Medical HistoryAortic Stenosis
type 2 Diabetes Mellitus
DISEASE
Hypertension
DISEASE
High cholesterol
Coronary Artery Disease
DISEASE
Benign Prostatic Hypertrophy-retention after surgeryPast Surgical HistoryCoronary Bypass Grafting 15 yrs ago at BIscholesystectomyRt shoulder rotator cufftonsillectomyleft index finger surgeryleft ring finger trigger surgeryeye surgerySocial History:Occupation:retired bus driverCigarettes: Smoked no [] yes [x] last cigarette 20 years agoOther Tobacco use:noneETOH: Admission Date: [**2182-2-3**] Discharge Date: [**2182-2-9**]Service:HISTORY OF THE PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-oldfemale with a history of critical AS paroxysmal atrial
fibrillation hypertension tachy-brady syndrome
DISEASE
whopresented to the Emergency Room with
chest pain
DISEASE
. In the EDthe blood pressure was noted to be elevated at 230-270systolic. The patient was given sublingual nitroglycerinhydralazine and subsequently her blood pressure decreasedinto the 80s. The patient was then noted to have ST segmentsin V4 through V6 and substernal
chest pain
DISEASE
started aftereating. The patient reports that the
chest pain
DISEASE
was [**10-13**]squeezing sensation. .................... The patientreports an episode of similar
pain
DISEASE
months ago. The patientdenied any
dyspnea
DISEASE
on exertion however she does reportlightheadedness. In the ED the patient was subsequentlystarted on Neo-Synephrine.PAST MEDICAL HISTORY:1. Paroxysmal
atrial fibrillation
DISEASE
.2. SVT
tachy-brady
DISEASE
syndrome.3.
Hypertension
DISEASE
.4. AS with valve area 0.7 cm squared.5. Arthritis.6. TR 2Admission Date: [**2119-9-19**] Discharge Date: [**2119-9-28**]Date of Birth: [**2053-4-8**] Sex: MService: CARDTHORHISTORY OF PRESENT ILLNESS: This is a 63 year old gentlemanwith known
coronary artery disease
DISEASE
who is status postmultiple percutaneous transluminal coronary angioplasties andstents with brachy therapy to his right coronary artery whowas admitted to [**Hospital6 3872**] on [**9-14**] afterthree to four hours of
chest pain
DISEASE
and pressure. The patientruled out for a
myocardial infarction
DISEASE
. The patient underwentrepeat cardiac catheterization which showed a 40 or 50% leftmain lesion 70% left anterior descending lesion 50% ramuslesion and a 30% right coronary artery lesion. The patientwas transferred to [**Hospital1 69**] foroperative treatment.PAST MEDICAL HISTORY:1. Coronary
artery disease
DISEASE
.2. Status post percutaneous transluminal coronaryangioplasty and stent to right coronary artery.3.
Hypertension
DISEASE
.4.
Hypercholesterolemia
DISEASE
.5.
Diabetes mellitus
DISEASE
diet controlled.6. History of
colon cancer
DISEASE
status post sigmoid resection in[**2104**].ALLERGIES: No known
drug allergies
DISEASE
.PREOPERATIVE MEDICATIONS:1. Enteric coated aspirin 325 mg p.o. q. day.2. Protonix 40 mg p.o. q. day.3. Plavix 75 mg p.o. q. day.4. Hyzaar 100/25 one tablet p.o. q. day.5. Zocor 20 mg p.o. q. day.6. Nitropaste one half inch q. four hours.7. Clonidine patch 0.1 q. Friday.REVIEW OF SYSTEMS: The patient denied cerebrovascularaccident GI bleedAdmission Date: [**2133-9-3**] Discharge Date: [**2133-9-6**]Date of Birth: [**2051-5-31**] Sex: MService: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 4095**]Chief Complaint:
fever
DISEASE
Major Surgical or Invasive Procedure:EGDHistory of Present Illness:82y/o Cambodian-speaking man with DM HTN presents with one dayof subjective
fever
DISEASE
and night sweats. Pt reports single episodeof
nausea
DISEASE
with a little
vomit
DISEASE
last night with no identifiabletriggers. ROS positive for black stools and
cough
DISEASE
of 1 mo. Ofnote pt had a cystoscopy on [**8-27**]. Denies weight changes HAcp sob abd
pain
DISEASE
focal neurol deficits
abnormal bowel
DISEASE
movements
hematochezia
DISEASE
.In the ED initial vital signs were 98.6 85 109/64 (baselinesbp 150's) RR 16 SAT 100%. Exam was notable for guaic Admission Date: [**2178-5-28**] Discharge Date: [**2178-6-3**]Date of Birth: [**2114-2-8**] Sex: MService: MED
Allergies
DISEASE
:Doxepin / Levofloxacin / OxycontinAttending:[**First Name3 (LF) 242**]Chief Complaint:SOB x 2dMajor Surgical or Invasive Procedure:noneHistory of Present Illness:64 yo M w/ PMHx as below presented to ED on [**5-29**] w/
hypercarbic
DISEASE
respiratory failure
DISEASE
(initial ABG [**5-28**]: 7/29/92/Admission Date: [**2159-3-29**] Discharge Date: [**2159-4-2**]Service: MEDICINE
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 1990**]Chief Complaint:
hypoglycemia
DISEASE
Major Surgical or Invasive Procedure:none.History of Present Illness:Ms [**Known lastname **] is an 88 year old Cantonese-dialect speaking female whopresents from [**Hospital6 1643**] Center (nursing home) for
hypoglycemia
DISEASE
.Around noon on day of admission staff at her nursing homenoticed she had become less responsive and was unable to moveher extremities. Finger stick was 96. She had just beenadministered SC heparin for
DVT
DISEASE
prophylaxis. Given concern fora
stroke
DISEASE
paramedics were called. When they arrived herglucose was apparently low and glucagon was administered. An IOwas placed in the left leg and an amp of D50 was administered.She was brought to the ED where blood sugar was noted to be 16. She received another amp of D50. Glucose improved transientlybut again came down to 40. Intravenous dextrose (D10W) wasstarted. She had improvement but several additionalhypoglycemic episodes.Her white count was noted to be 15000 and a lactate was 4.0.Her blood pressure remained normotensive. Her temperature was99.6. She had a CT head and abdomen/pelvis which revealed no
infectious
DISEASE
focus. She does have
ulcers
DISEASE
of dorsum of both lowerextremities which were treated with keflex 2 weeks priorAdmission Date: [**2195-8-26**] Discharge Date: [**2195-9-11**]Date of Birth: [**2153-1-25**] Sex: MService: NEUROSURGHISTORY OF PRESENT ILLNESS: The patient is a 42-year-oldgentleman with a past medical history of cerebellar
astrocytoma
DISEASE
diagnosed in [**2188**] by biopsy. He then followed upwith radiation therapy. The patient was known to haverecurrence of his
tumor
DISEASE
by biopsy on [**2195-5-26**]. He did nothave chemotherapy secondary to
infectious
DISEASE
issues. Thepatient was noted to have increased
unsteadiness of gait
DISEASE
pera clinic note.The patient came in with a one day
headache
DISEASE
on the left and
vomiting
DISEASE
times four days. He said that the left side
numbness
DISEASE
and
weakness
DISEASE
was worse. The patient also had ahistory of
diabetic complications
DISEASE
from steroids. He had ahead CT scan on admission which showed a large
bleed
DISEASE
intothe site of the prior
tumor
DISEASE
.PAST MEDICAL HISTORY: The past medical history included
hepatitis B
DISEASE
positive PPD positive
herpetic keratitis
DISEASE
epididymitis
DISEASE
and piloid
astrocytoma
DISEASE
which was recurrent.PAST SURGICAL HISTORY: The patient had biopsies times twothe last one being in [**2195-5-26**].ALLERGIES: The patient had no known drug
allergies
DISEASE
.PHYSICAL EXAMINATION: On physical examination the patienthad a blood pressure of 140/94 a heart rate of 60 arespiratory rate of 16 and an oxygen saturation of 100% onroom air. He was awake alert and in no acute distress. Theheart had a regular rate and rhythm with an S1 and S2. Thelungs were clear bilaterally. The abdomen was softnontender and nondistended with positive bowel sounds.Neurologically the pupils were unequal and reactive with theright being greater than left in size. On the left therewas no lateral gaze. The tongue was midline. The leftfinger-to-nose was inaccurate. There was a left facialdroop. The left upper extremity was [**4-30**] and the left lowerextremity was [**4-30**]. The patient had no drift. He was alertand oriented times three. Speech was fluent. He wasfollowing commands.RADIOLOGY: A CT scan showed a 3 cm
bleed
DISEASE
with significantmass effect with an
obstructive hydrocephalus
DISEASE
.LABORATORY DATA: On admission the patient had a sodium of140 potassium of 3.7 chloride of 101 bicarbonate of 24BUN of 12 creatinine of 0.7 and glucose of 161. There was awhite blood cell count of 7000 hematocrit of 44.5 andplatelet count of 294000. Prothrombin time was 13 partialthromboplastin time was 29 and INR was 1.1.HOSPITAL COURSE: The patient was admitted to the surgicalintensive care unit. On [**2195-8-26**] the patient went to theoperating room for a left suboccipital craniotomy forevacuation of
hematoma
DISEASE
and right frontal drain placementwithout complications.The patient continued to be monitored in the surgicalintensive care unit. He was awake alert following commandsand moving all extremities strongly. He did have a leftupper motor neuron seventh nerve palsy which was there priorto surgery. Vital signs remained stable. The ventriculardrain was pulled out by the patient on [**2195-8-29**] and wasreplaced. The patient was extubated on postoperative day #1.On [**2195-8-31**] the patient became tachypneic requiringintubation for full
respiratory failure
DISEASE
. On neurologicalexamination the patient was following commands. He had leftlateral gaze to the midpoint but was unable to go to extremelateral gaze on the left. The right eye had slight lateralgaze deviation. He was following simple commands. He haddecreased strength on the right but improved with no focaldrift. The patient was extubated on [**2195-9-2**] and had aswallow study which showed that the patient was aspiratingwith all consistencies. Therefore the patient was maden.p.o. and a feeding tube was placed.A family meeting was held with the family to discuss thegrave prognosis of the patient's condition. The patient wasinitially made Admission Date: [**2196-3-17**] Discharge Date: [**2196-3-19**]Date of Birth: [**2153-1-25**] Sex: MService: MICU/[**Location (un) **]HISTORY OF PRESENT ILLNESS: This is a 43 [**Hospital **] nursinghome resident who is Ethiopian speaking with a history ofrecurrent inoperable
cerebellar astrocytoma
DISEASE
with swallowingdysfunction
weight loss
DISEASE
and subsequent functional decline.The patient had recently pulled out his J tube was refusingsupplement nutrition. The patient was seen by Dr. [**Last Name (STitle) 724**] whois his neuro-oncologist two weeks ago and told that he had anextremely poor prognosis. He was seen by his primary carephysician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 4813**] [**Last Name (NamePattern1) 3501**] one week prior to admission with a
cough
DISEASE
and reportedly wished to spend the remainder of hislife at home. He is interested in pursuing a hospice. Theevening of admission the patient was alert and responsivebut had refused dinner and his evening medications theprevious night. He was found by a CMA at the nursing home tobe unresponsive at 1:45 a.m. He was transferred to [**Hospital1 1444**] and found to be
febrile
DISEASE
witha temperature of 104 intubated for airway protection and achest x-ray was obtained.PAST MEDICAL HISTORY: 1. Recurrent inoperable cerebellar
astrocytoma
DISEASE
diagnosed [**2188-2-26**] treated with x-raytherapy at [**Hospital6 1708**] on a Decadron taper.Recurrence noted on brain biopsy by [**2195-5-26**]. He had asubsequent bleed of [**2195-8-26**] and
hydrocephalus
DISEASE
craniotomy and shunt but is not a candidate forchemotherapy. 2. History of aspiration
pneumonia
DISEASE
. 3.History of positive PPD with a negative chest x-ray in [**2187**]completed six months of INH prophylaxis. 4. History of
schistosomiasis
DISEASE
and
Strongyloides
DISEASE
while on Decadron. 5.
Diabetes
DISEASE
secondary to steroids. 6. History of
herpes
DISEASE
keratitis
DISEASE
. 7.
Swallowing dysfunction
DISEASE
status postpercutaneous endoscopic gastrostomy 8. Hepatitis Bpositive. 9. History of
malaria
DISEASE
in [**2187**] treated withChloroquine.ALLERGIES: The patient has no known drug
allergies
DISEASE
.MEDICATIONS ON ADMISSION: 1. Decadron 2 mg po q.i.d. 2.NPH 6 units q.a.m. and 6 units q.p.m. 3. Regular insulinsliding scale. 4. Acyclovir 400 mg po b.i.d. 5. Multivitamin one po q.d. 6. Colace 100 mg po b.i.d. 7. PredForte ophthalmologic drops OD b.i.d. 8. Polysporin ointmentone drop to OS b.i.d.SOCIAL HISTORY: The patient came to the US from [**Country 4825**] in6/93. He is separated from his wife and children. He livedat [**Hospital 2670**] Nursing Home in [**Location (un) **].PHYSICAL EXAMINATION ON ADMISSION: Temperature 104 rectally.Blood pressure 120/70. Heart rate 111. Respiratory rate 20.O2 sat 97%. He was intubated. His right pupil was deviatedto the right and nonreactive. His left pupil was 3 mm to 2mm reactive. His neck was soft supple with no
lymphadenopathy
DISEASE
. Heart was tachycardic with no murmurs. Hischest was clear to auscultation bilaterally. His abdomen wassoft and nontender. He was heme negative on rectalexamination. His extremities were warm and well profuse.Neurologically he was unresponsive. He was on a ventilatorwith settings of IMV of 600 by 12 5 of PEEP 5 of pressuresupport and 100% FIO2.LABORATORY: His white count was 8.4 hematocrit 38.9platelets 167. Sodium 143 potassium 3.7 chloride 105bicarb 20 BUN 26 creatinine 1.1 glucose 248. CT 14.2 INR1.4 PTT 30.8. Sputum had 4Admission Date: [**2165-3-31**] Discharge Date: [**2165-4-13**]Service: CARDIOTHORACIC
Allergies
DISEASE
:Sulfa (Sulfonamides)Attending:[**First Name3 (LF) 1283**]Chief Complaint:worsening
shortness of breath dyspnea
DISEASE
on exertion and
edema
DISEASE
Major Surgical or Invasive Procedure:s/p AVR(27mmCE pericardial) MV repairs/p tracheostomyHistory of Present Illness:Mr. [**Known lastname 1662**] has had a long standing murmur had done well until 1year PTA when he began developing SOB DOE
orthopnea
DISEASE
and pedal
edema
DISEASE
.Past Medical History:1:aortic stenosis2:mitral regurgitation3:atrial
fibrillation
DISEASE
4:s/p
DISEASE
pacemaker insertion5:h/o
endocarditis
DISEASE
6:HTN7:BPH
8:s/p
DISEASE
R THR9:s/p L TKRPertinent Results:[**2165-4-12**] 02:15AM BLOOD WBC-10.5 RBC-3.30* Hgb-9.8* Hct-30.6*MCV-93 MCH-29.8 MCHC-32.1 RDW-13.4 Plt
Ct-234
DISEASE
[**2165-4-12**] 02:15AM BLOOD Plt
Ct-234
DISEASE
[**2165-4-12**] 02:15AM BLOOD PT-12.9 PTT-26.6 INR(PT)-1.1[**2165-4-12**] 02:15AM BLOOD Glucose-110* UreaN-48* Creat-1.2 Na-133Cl-88* HCO3-40*[**2165-4-12**] 11:25AM BLOOD Type-ART pO2-81* pCO2-59* pH-7.44calHCO3-41* Base
XS-12
DISEASE
Brief Hospital Course:Mr. [**Known lastname 1662**] was admitted to [**Hospital1 18**] [**3-31**] for pre operativeanticoagulation. He was taken to the operating room on [**4-2**]with Dr. [**Last Name (STitle) **] for an AVR/MV repair. He tolerated theprocedure well and was transferred to the ICU. He was weanedand extubated from mechanical ventilation on POD#1. He became
oliguric
DISEASE
despite adequate cardiac output and normal creatinine.He was started on dopamine and Natrecor. He was also noted tohave worsening oxygenation and increased work of breathing. Hewas started on BiPAP with good results. He underwent a renalultrasound which showed no
hydronephrosis
DISEASE
. He was given
aggressive diuretic
DISEASE
therapy which resulted in adequate urineoutput. His creatinine only minimally rose to 1.3 and hegradually required only minimal diuretics for adequate urineoutput. His respiratory status continued to be problem[**Name (NI) 115**] andhe required BiPAP for several days. An ENT consult was obtainedto rule out upper
airway edema
DISEASE
. A bedside fiberoptic examshowed an very large uvula and no
airway edema
DISEASE
. It was thoughtthat the uvula was causing
airway obstruction
DISEASE
worsened by fluid
overload
DISEASE
and the decision was made to place a tracheostomy. Heunderwent tracheostomy on [**4-9**] with a #8 per fit trach placedwithout difficulty. He was weaned from the ventilator over thenext day and was placed on trach mask with Passey Muir valve on[**4-11**]. An attempt to rest the patient on the ventilator made himuncomfortable and he requested to not be put back on. Hisarterial blood gasses showed adequate oxygenation and balancedacid base status. He was started on Coumadin after histracheostomy for his
atrial fibrillation
DISEASE
and is cleared fordischarge to rehab on [**4-12**]Medications on Admission:coumadinhytrin 2mg po qdlasix 80mg po qdMVIfolateDischarge Medications:1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets POQ4H (every 4 hours) as needed for
pain
DISEASE
.2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every4 hours) as needed for temperature Admission Date: [**2158-6-16**] Discharge Date: [**2158-6-19**]Date of Birth: [**2103-3-15**] Sex: FService:ADMISSION DIAGNOSIS: Right flank
pain
DISEASE
.HISTORY OF PRESENT ILLNESS: The patient is a 55 year-oldmale status post kidney transplant in [**2149**] history of
hypertension dyspnea diabetes anemia
DISEASE
who has been havingsome
abdominal pain
DISEASE
. The patient had recently been dischargedfrom the [**Hospital1 69**] on [**2158-5-1**]with similar complaints on the medicine service. A transverseright upper quadrant
pain
DISEASE
radiating to the back and shoulder8 out of 10. Patient is status post renal transplant [**Numeric Identifier 4837**]and has been off dialysis ever since the surgery. The patientwas well until three days ago when sharp right upper quadrant
pain
DISEASE
who has not been able to tolerate anything by mouth.Patient has
chronic constipation
DISEASE
no
diarrhea
DISEASE
.
Last bowel
DISEASE
movement was on [**2158-6-14**]. The
pain
DISEASE
has progressivebecome more persistent and is associated with low grade
fevers
DISEASE
of 99. Patient denies
shortness of [**Year (4 digits
DISEASE
) 1440**]
chest pain
DISEASE
hematuria dysuria
DISEASE
no dark urine or [**Male First Name (un) 1658**] colored stools. Onlast admission the patient had a work up all of which wasnegative including ultrasound HIDA scan abdominal CT and CTof chest.PAST MEDICAL HISTORY:1.
Hypertension
DISEASE
.2. Diabetes.3. Status post renal transplant in [**2149**].4. Sciatica.5. Multinodular
goiter
DISEASE
.6. Cataract surgery.7. Hyperlipidemia.8. Depression.9. History of
shoulder pain
DISEASE
.10. History of
vertigo
DISEASE
.11. History of
nephrolithiasis
DISEASE
.MEDICATIONS ON ADMISSION: Neural 100 in the morning 50 inthe afternoon. Diltiazem 240 mg q day CellCept [**Pager number **] b.i.d.Lipitor 5 mg q day prednisone 10 mg 10 mg q.o.d. lisinopril5 to 10 mg q day Lasix 60 q day Ativan q.A.M. aspirin 81mg q day lactulose q.o.d. Lantus 30 units q.P.M. slidingscale.ALLERGIES: No known
drug allergies
DISEASE
.SOCIAL HISTORY: No tobacco no alcohol no drugs.FAMILY HISTORY: Noncontributory.LABORATORIES ON ADMISSION: WBC 7.0 hematocrit 29.6platelets 264 sodium 138 5.3 104 22 BUN/creatinine51/1.5 with glucose 174. Ultrasound was obtained [**2158-6-15**] demonstrating distended gallbladder without evidence of
cholecystitis
DISEASE
. No evidence of
intrahepatic or extrahepatic
biliary duct dilatation
DISEASE
. Patient also had a CT of the abdomenand pelvis on [**2158-6-15**] demonstrating 1) distendedgallbladder with no
gallstones
DISEASE
divide or evidence of acute
cholecystitis
DISEASE
. There is no intra or extrahepatic biliary ductdilatation. 2) Stable appearance of the shunts of thetransplant kidney with unchanged appearance of
perinephric
DISEASE
stranding around the transplant kidney. 3) There is noevidence of acute pathology to explain the patient's
pain
DISEASE
.HOSPITAL COURSE: Patient was admitted to
Dr.[**Name
DISEASE
(NI) 4838**]service. Gastroenterology was consulted and it was suggestedfor patient to have an upper endoscopy. Nephrology wasconsulted. Urine blood and sputum were obtained which wereall unremarkable. On [**2158-6-19**] patient had endoscopydemonstrating normal esophagus normal stomach normalduodenum normal upper endoscopy to second portion of theduodenum. Patient felt better and on [**2158-6-19**] patientwas discharged to home.Patient was discharged on the following medications: Neural100 mg 100 mg p.o. q.A.M. and Neural 50 mg q. P.M. diltiazem240 mg 1 p.o. q day atorvastatin calcium 25 mg q day Lasix60 mg q day aspirin 81 mg q day lactulose p.r.n. MMF 500mg b.i.d. prednisone 10 mg q.o.d. Dilaudid 2 mg 1 to 2 p.o.q 6 hours p.r.n.Patient to follow up with nephrology by calling [**Telephone/Fax (1) 673**]for an appointment. Also follow up with Dr. [**First Name8 (NamePattern2) 110**] [**Last Name (NamePattern1) 656**] [**Telephone/Fax (1) 4839**]. Another appointment is with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2158-6-21**] at 9 A.M. and also with physical therapy which wasscheduled on [**2158-6-20**] at 2:30 P.M. at 1[**Location (un) 4840**]in [**Location (un) **] [**State 350**]. Patient should calltransplant surgery immediately at [**Telephone/Fax (1) 673**] if any
fevers
DISEASE
chills nausea vomiting abdominal pain hesitancy
DISEASE
in
urinary shortness
DISEASE
of [**Last Name (LF) 1440**] [**First Name3 (LF) 691**] sustained right upperquadrant or an increase in lower extremity edema.FINAL DIAGNOSIS: Probable costochondritis.SECONDARY DIAGNOSIS: Status post renal transplant. [**Name6 (MD) **] [**Name8 (MD) **] [**MD Number(1) 4841**]Dictated By:[**Last Name (NamePattern1) 4835**]MEDQUIST36D: [**2158-9-28**] 10:38:33T: [**2158-9-28**] 11:42:00Job#: [**Job Number 4842**]Admission Date: [**2162-6-8**] Discharge Date: [**2162-6-18**]Date of Birth: [**2103-3-15**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4854**]Chief Complaint:
Shortness of [**First Name3 (LF) 1440**]
Major Surgical or Invasive Procedure
DISEASE
:BipapHistory of Present Illness:59 year old female with
type 1 diabetes hypertension
DISEASE
frequent
UTI
DISEASE
on tetracycline immunosuppresion
ESRD
DISEASE
s/p CRT in [**2149**] whopresents with acute onset of
dyspnea
DISEASE
..The patient was recently admitted from [**Date range (1) 4859**]/09 for
pyelonephritis
DISEASE
and e. coli
bacteremia
DISEASE
. She presented with
weakness
DISEASE
and
fever
DISEASE
. She was on Zosyn and ciprofloxacin untilsensitivies returned and then switched to oral ciprofloxacin.She was on tetracycline for
UTI
DISEASE
suppression by her ID MD Dr.[**Last Name (STitle) 724**]. She was discharged with 2 week course of ciprofloxacin.Also Cr elevated and felt to be
prerenal
DISEASE
secondary to
bacteremia
DISEASE
but also with some component of
ATN
DISEASE
which resolvedwith IVFs. Diuretics slowly restarted upon discharge..The patient went to her appointment with her NP this morning.Today her wt was noted to be up 28 lbs from [**2162-5-20**]. The planwas to increase lasix from 80 mg [**Hospital1 **] to 120 mg qAM and 80 mg QPMand to follow up with Dr. [**Last Name (STitle) 1366**] on [**6-11**]. After herappointment she went home and around noon while walking shefelt acute onset of
dyspnea
DISEASE
. She notes increased wt
gain
DISEASE
sinceher recent discharge from [**Hospital1 18**] on [**6-1**] but notes that she ison increased doses of her lasix. She also denies any medicationnoncompliance. Denies dietary
indiscretions
DISEASE
but has beeneating only chicken soup which her daughters prepare for her (1tsp salt in each batch). She also drinks 2 glasses of cranberry
juice cup of coffee and cup of tea. She also has been eatingmany low salt saltine crackers and ginger ale per her daughter.[**Name (NI) **] daughter visited her the night prior to discharge and notedthat her mom wsa tired and weak but not SOB. Today though thepatient called her daughter and complained of Admission Date: [**2162-8-8**] Discharge Date: [**2162-8-12**]Date of Birth: [**2103-3-15**] Sex: FService: MEDICINE
Allergies
DISEASE
:TetracyclineAttending:[**First Name3 (LF) 3624**]Chief Complaint:
Epigastric Pain
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:This is a 59 year old woman with history of
HTN DM
DISEASE
s/p renaltransplant in [**2150**] currently on cellcept and cyclosporinepresents with one week of
nausea
DISEASE
and
vomiting
DISEASE
.One week prior to presentation she has acute onset of
nausea
DISEASE
vomiting
DISEASE
and abd
pain
DISEASE
. She did not notice any blood in thevomitus. Her
pain
DISEASE
was [**8-2**] epigastric and radiated to the back.She has not had
pain
DISEASE
like this before. She denies drinkingalcohol. No recent spider bites. No change in her weightrecently. No personal or family history of
cancer
DISEASE
.She was recently admitted at [**Hospital1 **] for
dyspnea
DISEASE
attributed topulmonary edema/fluid
overload
DISEASE
. ECHO [**6-1**] shows mild
LVH
DISEASE
and EF55%. Prior to this she was admited for E. coli
pyelonephritis
DISEASE
and was treated with Zosyn and ciprofloxacin.She has history of
ESRD
DISEASE
s/p cadaveric renal transplant in [**2150**].She has a baseline cre of 2.5 (near her baseline). She has beenmantained on immunosupression with prednisone cellcept andcyclosporin (all of these were started more than one year agowithout recent changes). She also takes EPO for
anemia
DISEASE
..In the ED initial vs were: 97.4 63 160/63 18 99. Patient wasplaced NPO and given morphine for
pain
DISEASE
and ondasentron. RUQ USshowed a distened GB but without stones. No CBD dilatation. CXRwithout acute changes. While in the ED her urine output was 150cc over a period of 5 hrs. She received 1 lt NS. Prior totransfer her vitals were 97.6 60 149/44 18 99RA..Review of sytems:(Admission Date: [**2158-1-31**] Discharge Date: [**2158-2-4**]Date of Birth: [**2111-2-7**] Sex: FService:ADMITTING DIAGNOSIS: Pelvic mass.POSTOPERATIVE DIAGNOSIS:
Ovarian cancer
DISEASE
.HISTORY OF THE PRESENT ILLNESS: The patient was admitted forwith symptoms of
bloating
DISEASE
. The patient's workup revealed alarge
pelvic mass
DISEASE
that was suspicious for
ovarian cancer
DISEASE
.PAST MEDICAL HISTORY: Significant for
migraines
DISEASE
.PAST SURGICAL HISTORY: Noncontributory.PAST OBSTETRICAL HISTORY: Noncontributory.HOSPITAL COURSE: The patient was admitted for an exploratorylaparotomy TAH/BSO peritoneal washings omentectomy anddebulking and pelvic lymph node dissection. The estimated
blood loss
DISEASE
of the procedure was 250 cc. The procedure wasuncomplicated. The patient'spostoperative course was complicated by an episode of
respiratory arrest
DISEASE
believed to be related to narcoticsensitivity. The patient had received in total 3 mg ofmorphine IV and 4 mg of Dilaudid IV and then 4 mg of
Dilaudid
DISEASE
subcutaneously. A code was called. The patient's airway wasimmediately secured and she was immediately bagged. Narcanwas given IV and the patient responded well with a vigorousrespiratory effort.The patient was transferred to the MICU for closer monitoringand at that time was started on a
Narcan
DISEASE
drip. The patientdid well for the remainder of the night and the Narcan dripwas then discontinued in the early morning. The patient's
pain
DISEASE
control overnight was managed with a dose of p.o.Percocet early in the morning.The patient was called out of the MICU on postoperative daynumber one and transferred to the regular Postsurgical
Floor
DISEASE
.The patient's
pain
DISEASE
control was initially controlled withPercocet and then transitioned to Toradol and then finallyafter a consultation with the
Pain
DISEASE
Service was transitionedto Flexeril 10 mg t.i.d. and Motrin 600 mg q. six hours. Inaddition Physical Therapy consult was obtained to provideassistance with the patient in ambulation and mobility.The patient's urine output was adequate throughout her
hospitalization/postoperative
DISEASE
course. She began toleratingp.o. on postoperative day number one. On postoperative daynumber one she also began ambulating. The patient's Foleywas discontinued and she was voiding spontaneously. Hervital signs remained stable for the remainder of thehospitalization. Her abdominal examination had positivebowel sounds and was appropriately tender. Her incisionremained clean
dry
DISEASE
and intact. The patient will bedischarged to home on a full diet with Flexeril 10 mg t.i.d.and 600 mg of Motrin q. six hours simethicone 80 mg q. eighthours.DISPOSITION: The patient will be discharged to home.CONDITION ON DISCHARGE: Good. The patient will have homeVNA to assess her postoperative course.FOLLOW-UP: The patient will follow-up with Dr. [**First Name (STitle) 1022**] inapproximately one months time. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **] M.D. [**MD Number(1) 4871**]Dictated By:[**Name8 (MD) 4872**]MEDQUIST36D: [**2158-2-4**] 01:04T: [**2158-2-6**] 12:56JOB#: [**Job Number 4873**]Admission Date: [**2128-2-9**] Discharge Date: [**2128-2-26**]
Service: CARDIOTHORACIC SURGERYCHIEF COMPLAINT: A 78-year-old man transferred from [**Hospital6 4874**] status post
myocardial infarction
DISEASE
transferred to [**Hospital1 69**] forcardiac catheterization.HISTORY OF PRESENT ILLNESS: A 78-year-old man with pastmedical history significant for PMR hypertension with noknown history of
coronary artery disease
DISEASE
who presented atoutside hospital complaining of chest pressure radiating toneck when using a snow-blower. Pain subsided with rest butreturned with activity.He says three days ago he had the same symptoms when alsousing a snow-blower. No
dyspnea palpitations nausea
DISEASE
or
vomiting
DISEASE
at the time of chest pressure. Reports waking upwith
chest pain
DISEASE
approximately one week ago. Had jaw
pain
DISEASE
atthat time also. Also reports that over the past month he hashad increasing
chest pain
DISEASE
with exertion. Daughter who is aR.N states that he has had increased
dyspnea
DISEASE
with exertionx1 year.The patient was treated with Lopressor and started on Heparinand Aggrastat at [**Hospital6 4620**]. First set ofenzymes showed a CK of 162 MB are not available andtroponin of 40.6. He is currently
pain
DISEASE
free.PAST MEDICAL HISTORY:1. PMI x10 years on prednisone.2.
Hypertension
DISEASE
.3.
Gastroesophageal reflux disease
DISEASE
.4.
Hiatal hernia
DISEASE
.5. Pernicious
anemia
DISEASE
.6. Cholecystectomy.SOCIAL HISTORY: Smokes [**5-8**] cigars per day x40 years but noalcohol use none since [**2102**]. Retired [**Location (un) 86**] police officer.Lives with his wife in [**Name (NI) 1411**].FAMILY HISTORY: Both parents died of
strokes
DISEASE
in their 90s.MEDICATIONS AT HOME:1. Zantac 100 mg [**Hospital1 **].2. Norvasc no dose.3. Vioxx no dose.4. Prednisone 20 mg q day.5. Neurontin 100 mg q day.6. Flomax 0.4 mg q day.7. Tums no dose.ALLERGIES: Penicillin which causes a
rash
DISEASE
.PHYSICAL
EXAM
DISEASE
AT TIME OF ADMISSION: Heart rate 77 bloodpressure 151/93 respiratory rate 20 and O2 sat is 98% on 2liters. General: Pleasant-elderly man well appearing in noacute distress. HEENT: Pupils 1.5 mm. Oropharynx is moist.Lungs are clear to auscultation bilaterally with markeddiminished breath sounds throughout. Heart: Regular rateand rhythm normal S1 S2 with no murmur. Abdomen is softnontender nondistended with
positive bowel sounds
DISEASE
.Extremities with 2Admission Date: [**2129-7-19**] Discharge Date: [**2129-8-21**]Service: [**Doctor First Name 147**]
Allergies
DISEASE
:PenicillinsAttending:[**First Name3 (LF) 1481**]Chief Complaint:
Carcinoma
DISEASE
in situ and high grade
dyplasia of the distal stomach
Major Surgical
DISEASE
or Invasive Procedure:1. subtotal gastrectomy with roux en y reconstruction repair of
hiatal hernia
DISEASE
and fundoplication [**2129-7-19**]2. Exploratory laparotomy drainage of the abdomen small bowelresection with anastamosis placement of temporary mesh closure[**7-21**].3. Laparotomy closure of abdominal wall [**2129-7-25**]History of Present Illness:79 yo M with a 10 yr h/o GERD underwent an EGD in [**3-9**] whichshowed patchy lesions in the stomach. Biopsies revealedmetaplasia and suspicion gor early
gastric carcinoma
DISEASE
.Past Medical History:CAD sp CABG X 4 MVRGERDpolymyalgia
rheumatica
DISEASE
X 14 yrs on steriodsh/o
gallstone pancreatitis
DISEASE
sp cholecystectomy [**13**]'
prostate cancer
DISEASE
sp radiation in 94'Physical Exam:NADRRRCTABwell healed median sternotomysoft NTwell healed R subcostal incisionNo E/C/CNeuro grossly intactPertinent Results:[**2129-8-21**] 01:25AM BLOOD WBC-18.3* RBC-3.37* Hgb-10.0* Hct-29.4*MCV-87 MCH-29.8 MCHC-34.2 RDW-17.3* Plt Ct-57*[**2129-7-30**] 04:57PM BLOOD WBC-21.7* RBC-3.11* Hgb-9.3* Hct-28.4*MCV-91 MCH-29.8 MCHC-32.6 RDW-17.4* Plt Ct-78*[**2129-7-30**] 03:30AM BLOOD WBC-31.7* RBC-3.48* Hgb-10.0* Hct-33.5*MCV-96 MCH-28.6 MCHC-29.7* RDW-17.3* Plt Ct-86*[**2129-7-28**] 02:19AM BLOOD WBC-33.3* RBC-3.84* Hgb-10.9* Hct-36.4*MCV-95 MCH-28.4 MCHC-30.0* RDW-16.5* Plt Ct-66*[**2129-7-26**] 03:00AM BLOOD WBC-25.6* RBC-3.78* Hgb-11.5* Hct-34.3*MCV-91 MCH-30.4 MCHC-33.6 RDW-16.2* Plt
Ct-50
DISEASE
*[**2129-7-22**] 12:51PM BLOOD WBC-13.3*# RBC-4.20* Hgb-12.6* Hct-38.6*MCV-92 MCH-29.9 MCHC-32.5 RDW-16.1* Plt Ct-110*[**2129-7-21**] 11:39PM BLOOD WBC-6.5 RBC-4.01* Hgb-12.1* Hct-35.6*MCV-89 MCH-30.1 MCHC-33.9 RDW-15.6* Plt Ct-127*[**2129-7-21**] 07:40AM BLOOD WBC-1.5*# RBC-2.96* Hgb-8.5* Hct-27.3*MCV-92 MCH-28.8 MCHC-31.2 RDW-15.9* Plt Ct-222[**2129-7-19**] 01:04PM BLOOD WBC-11.5* RBC-3.64* Hgb-10.6* Hct-30.9*MCV-85 MCH-29.0 MCHC-34.1 RDW-15.5 Plt Ct-220[**2129-8-9**] 01:05PM BLOOD Neuts-48* Bands-32* Lymphs-15* Monos-3Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 NRBC-4* Plasma-1*[**2129-8-21**] 01:25AM BLOOD Plt Ct-57*[**2129-8-20**] 02:02AM BLOOD Plt Ct-20*[**2129-8-17**] 07:30PM BLOOD Plt Ct-84*#[**2129-8-14**] 02:03AM BLOOD Plt Ct-20*[**2129-8-11**] 02:59AM BLOOD Plt Smr-RARE Plt Ct-18* LPlt-3Admission Date: [**2178-11-15**] Discharge Date: [**2178-12-2**]Date of Birth: [**2114-2-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:Doxepin / Levofloxacin / OxycontinAttending:[**First Name3 (LF) 281**]Chief Complaint:
Respiratory Failure
DISEASE
Major Surgical or Invasive Procedure:Tracheostomy Placement[**First Name3 (LF) 282**] tube placementHistory of Present Illness:64 yo man with h/o lung CA s/p R pneumonectomy
COPD
DISEASE
mini-trachto manage secretions on home O2 who presents c/o 4 daysprogressively worsening SOB. Need to increase home O2 from 2 to3 liters. In ED ABG 7.39/62/163 on 2L NC (which is basically hisbaseline). Given combivent solumedrol clinda and azithro forpresumed
COPD
DISEASE
exacerbation. Initially admitted to MICU for closemonitoring started on Azithromycin and CTX switched to Ceftazgiven past history of Pseudomonas. Transferred to floor on[**11-17**] stable and at baseline. On floor patient had repeatedepisodes of
desaturation
DISEASE
with
tachypnea
DISEASE
. Became SOB on [**11-18**] inAM given Ativan 1 Morphine 2 and Valium 5 with some initialimprovement. Then found to be lethargic and ABG with PCO2 102pH 7.22. Brought to the ICU for further management.Past Medical History:
Lung carcinoma
DISEASE
status post right pneumonectomy.
Prostate cancer
DISEASE
status post resection.History of perioperative PE on anticoagulation.
Atrial fibrillation
DISEASE
on anticoagulation.
Hypertension
DISEASE
.
Diabetes type II
DISEASE
.
Obstructive sleep apnea
DISEASE
.
Hypercholesterolemia
DISEASE
.
B12 deficiency
DISEASE
.
Cataracts
DISEASE
Social History:He lives with his wife. [**Name (NI) **] has a 3-pack-per-day tobacco historybut quit in [**2174**] and an overall 160-pack-per-year history. Norecent history of alcohol use.Family History:Mother with
coronary artery disease
DISEASE
.Physical Exam:Upon Discharge:Gen: Alert NAD cooperative well appearingHEENT: PERRLA [**Year (4 digits) **] MMM/clear trach in placeCV: irreg rhythym reg rate no m/r/JVDPulm: coarse BS on the left transmitted BS on RAb: s/nd/[**Last Name (LF) **] [**First Name3 (LF) 282**] in placeExt: no LE
edema
DISEASE
2Admission Date: [**2105-6-21**] Discharge Date: [**2105-6-23**]Date of Birth: [**2032-9-11**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 348**]Chief Complaint:
Fever cough tachycardia
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Mr. [**Known lastname 4882**] is a 72 y.o. M with Stage III
CKD
DISEASE
likely from
hypertension
DISEASE
followed by Dr. [**Last Name (STitle) 4883**]
hypertension
DISEASE
and
gout
DISEASE
who presents with 5 days of
cough fever
DISEASE
and malaise. Thepatient reports that he has not been feeling well since Tuesday.He felt like he needed to see the doctor but put this off. Hehas been drinking [**12-26**] water bottles a day but not eating asnothing tastes good. He endorses subjective
fever
DISEASE
for last 5days as he felt hot. He also has had a productive
cough
DISEASE
of whitesputum that is new. He also endorsed feeling lightheaded withstanding but no
dizziness
DISEASE
.He has been drinking 1 L of [**First Name5 (NamePattern1) 4884**] [**Last Name (NamePattern1) 4885**] Black every 2 dayswith last drink on Monday. He called his neighbor as hecontinued to feel unwell today and he was brought in byneighbor. Admission Date: [**2143-1-21**] Discharge Date: [**2143-2-5**]Date of Birth: [**2090-5-26**] Sex: MService: MEDICINE
Allergies
DISEASE
:Nafcillin / cefazolinAttending:[**First Name3 (LF) 4891**]Chief Complaint:acute epidural abscess MSSA
bacteremia
DISEASE
Major Surgical or Invasive Procedure:1. Total laminectomy of L1 L2 L3 L4 and L5.2. Incision and drainage.3. Debridement.History of Present Illness:Mr. [**Known lastname **] is a 52-year-old male with medical historysignificant for
gout
DISEASE
involving the left ankle for 8 years
atrial fibrillation
DISEASE
on warfarin Hypertension Hyperlipidemiaand
gout
DISEASE
who presented in
atrial fibrillation
DISEASE
with rapidventricular response on [**2143-1-18**] and was later found to haveMSSA
bacteremia
DISEASE
. During the admission he required Medical ICUmonitoring for neurochecks and further evaluation of epiduralabscess.Pt initially presented to his PCP with an erythematous painfulleft ankle with concern for
gout
DISEASE
flare. When seen by his PCP[**Name10 (NameIs) **] was SOB and found to be in afib with rapid ventricularresponse. He was transferred to the [**Hospital3 2568**] ED where thepatient was evaluated by orthopedics who felt that the patienthad a painful left ankle with somewhat preserved passive rangeof motion and that his exam could be consistent with
cellulitis
DISEASE
of the lateral aspect of the ankle. Initial labs showed INR of7.4 Lactic acid of 1 WBC 18 BUN and creatinine of 44 and 0.8AST and ALT of 108 and 127 respectively Alkaline Phos 297 andC-reactive of 348. He was started on Ampicillin/sulbactam forantimicrobial coverage for possible
cellulitis
DISEASE
overlying
gout
DISEASE
.However on the night of [**1-18**] he spiked to 102.3 and prelimcultures grew GPC's and Vancomycin was added. He had x-rays ofthe left ankle that showed no acute
fracture
DISEASE
and LENI wasnegative for
DVT
DISEASE
. CTA was done at that time which showed no PEbut showed pulmonary nodules.Subsequently blood cultures in [**12-29**] bottles grew out MSSAbacteria and she was switched to oxacillin 2g IV q4hrs. TTE wasdone which was poor quality but showed no
vegetations
DISEASE
. For his
Afib
DISEASE
he was treated with IV diltiazem and subsequentlyswitched to IV and then po dilt. Imaging done at that time wasconcerning for an epidural collection and possibly
abcess
DISEASE
in theL2 L3 and L4 level. The provisional report was reported by Dr.[**Last Name (STitle) 4892**] radiologist at [**Hospital1 18**]. The patient was evaluated by theNeurosurgeon Dr. [**First Name (STitle) **] [**Name (STitle) 3704**] who recommended that thepatient be transfered the patient to [**Hospital1 18**] as the patientrequires more MRI of the Spine (Thoracic and Cervical) and a MRIbrain to rule out any more extensive pathology.On arrival to the MICU the patient was somnolent butarousable. He has diffuse
wheezing
DISEASE
bilaterally. He endorses back
pain
DISEASE
and
neck pain
DISEASE
. His vital signs are HR 111 BP 103/72 O2 96%2L.The patient was subsequently stabilized in the medical ICU andlater transferred to the hospital medicine service.Review of systems:(Admission Date: [**2125-8-16**] Discharge Date: [**2125-8-24**]Date of Birth: [**2061-8-29**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 165**]Chief Complaint:
Chest burning
DISEASE
Major Surgical or Invasive Procedure:[**2125-8-20**] CABG x 5 (LIMA to LAD SVG to Ramus SVG to OM1 and OM2sequentially SVG to PDA)History of Present Illness:63 year old white male with no previous cardiac history whodeveloped
chest burning
DISEASE
on exertion while on vacation.Cardiology workup revealed non-ST elevation MI. Cardiaccatheterization and coronary angiography reveals severe 3VD.Past Medical History:
Coronary artery disease
DISEASE
NSTEMI [**2125-8-1**]infrarenal AAA
prostate cancer
DISEASE
s/p seed implants [**2121**]melanoma- anterior abd wall- awaiting excisionSocial History:Manufacturer of stair cases. Lives with wife. Quit smoking 40years ago with 12 pyhFamily History:No family history of
coronary disease
DISEASE
.Physical Exam:Pulse: 73 Resp: 14 O2 sat: 95%RAB/P Right: 149/100 Left:Height: 68Admission Date: [**2129-3-9**] Discharge Date: [**2129-3-17**]Date of Birth: [**2082-11-14**] Sex: FService: MEDICINE
Allergies
DISEASE
:Bactrim DSAttending:[**Doctor First Name 3298**]Chief Complaint:
pain
DISEASE
crisisMajor Surgical or Invasive Procedure:right internal jugular central venous catheter placementHistory of Present Illness:46 yo F with
sickle cell anemia
DISEASE
multiple admission for
pain
DISEASE
crises who presented with an acute onset bilateral kneeshoulder hip and
chest pain
DISEASE
consistent with prior
pain
DISEASE
crises.The patient experienced the acute onset of
knee pain
DISEASE
the morningof her admission while brushing her teeth about 20 minutesafter getting up. This was followed by
chest shouler
DISEASE
and hip
pain
DISEASE
bilaterally. Given the severe
pain
DISEASE
the patient presentedto the emergency room.In the ED initial vital signs were 98.2 95 133/81 20 100%4L/NC. The patient was given normal saline 1 liter and dilaudid1 mg IV x 3.There was concern that she was developing acute chest and shewas admitted to the MICU. She complained of significant
pain
DISEASE
when she arrived the the ICU.Past Medical History:1) Sickle Cell Disease- Hgb SS: diagnosed at age 3 withcomplications including
avascular necrosis
DISEASE
of R hip acute chestsyndrome and
pulmonary infarction
DISEASE
. Spleen autoinfarction.-Pneumococcal vaccine [**2126**]-Influenza vaccine [**2126**]-H Flu & Meningococcal vaccine [**1-/2114**]2)
Hepatitis
DISEASE
C- Genotype 1B. Dx in [**2106**]'s believed to be due tofrequent transfusions. Liver biopsy [**3-24**] stage III
fibrosis
DISEASE
. In[**2120**] was on peg interferon & ribavarin but d/c'd due to
neutropenia
DISEASE
.3) S/P cholecystectomy for
gallstones
DISEASE
in [**2096**]'s4) S/P appendectomy in [**2096**]'s5. Proteinurea- Started lisinopril 2.5 mg 1 po daily [**4-/2127**]Social History:Married works as executive assistant for housing development.Social smoking in high school none currently. Rare ETOH useonly on holidays. Denies drug use.Family History:Multiple family members on mother's side of family with
sickle
DISEASE
cell disease
DISEASE
.Physical Exam:Admission Physical ExamVital signs: 99.2 114/70 100 18 100%/2LGen: Appears uncomfortable complain in diffuse arthalgia.HEENT: NC/AT. Anicteric sclerae. Moist mucous membranes. OPclear.Neck: Supple.Resp: Normal respiratory effort. CTAB.CV: RRR. Normal s1 and s2. No M/G/R.Abd: Admission Date: [**2176-7-17**] Discharge Date: [**2176-7-22**]Date of Birth: [**2093-9-13**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4765**]Chief Complaint:SOBMajor Surgical or Invasive Procedure:noneHistory of Present Illness:82 y/o F h/o
DM2
DISEASE
carotid stent on ASA/plavix
HTN
DISEASE
a/w 4 days hxof worsening SOB. There is some at rest but more noticable atexertion. Developed
orthopnea
DISEASE
PND but she did not notice
swelling
DISEASE
in her lower extremities. She noticed that today shehad
chest tightness
DISEASE
but no
chest pain
DISEASE
..ROS: no n/v/d/fevers
chills
DISEASE
or URI. No blood in stools therehave been no changes in her diet or her thyroid medications.Past Medical History:1.
PVD
DISEASE
s/p [**Country **] stent2. DM II3.
HTN
DISEASE
4.
hypothyroidism
DISEASE
5.
hyperlipidemia
DISEASE
6. L eye detachment7. h/o
diabetes
DISEASE
inspidus after pregnancy - not an active issue8.
hearing loss
DISEASE
Social History:SH: Denies tobacoo history. Minimal alcohol use. Lives withhusband very supportive family.Family History:noncontributoryPhysical Exam:Admission Physical Exam:PE: 185/54 77 38 99% NRGen: resp distress WDWN.HEENT: peerla eomi ncat on non-rebreatherAdmission Date: [**2176-7-23**] Discharge Date: [**2176-7-26**]Date of Birth: [**2093-9-13**] Sex: FService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 443**]Chief Complaint:
Shortness of Breath
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:82 y/o F h/o
DM2
DISEASE
carotid stent on ASA/plavix
HTN
DISEASE
recentlyadmitted and discharged from [**Hospital Unit Name 196**] yesterday for
CHF
DISEASE
exacerbationand
UTI
DISEASE
. PT became SOB Admission Date: [**2190-3-15**] Discharge Date: [**2190-3-23**]Service: CCUHISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 4924**] is an 85-year-oldmale with a history of three
vessel coronary artery disease
DISEASE
status post coronary artery bypass graft in [**2181**] history of
congestive heart failure
DISEASE
with ejection fraction of 34% onexercise MIBI in [**2189-6-12**] paroxysmal
atrial fibrillation
DISEASE
mitral regurgitation
DISEASE
who presents with two to three weeks ofincreasing
dyspnea
DISEASE
with minimal exertion. Denies dyspnea atrest
chest pain
DISEASE
paroxysmal
nocturnal dyspnea
DISEASE
or
orthopnea
DISEASE
.His
dyspnea
DISEASE
on exertion has been worsening over the lastcouple of months but he has noticed over the last couple ofweeks that he is unable to walk even five yards withoutsignificant symptoms. He was directly admitted for electiveSwan-Ganz tailored
congestive heart failure
DISEASE
therapy.PAST MEDICAL HISTORY:1. Coronary
artery disease
DISEASE
status post coronary arterybypass graft in [**2181**]2. Most recent cardiac catheterization [**2187-1-12**]Admission Date: [**2191-7-18**] Discharge Date: [**2191-7-24**]
Service: CCUTHIS REPORT WILL BE CONCLUDED IN AN ADDENDUM.HISTORY OF PRESENT ILLNESS: The patient is an 86 year oldgentleman with a history of
coronary artery disease
DISEASE
statuspost three vessel coronary artery bypass graft in [**2181**] withthe following anatomy: Left internal mammary artery to leftanterior descendingAdmission Date: [**2192-3-25**] Discharge Date: [**2192-3-29**]Date of Birth: Sex: MService: GEN [**Doctor First Name 147**]The patient is transferred to the Cardiology Service on[**2192-3-29**].HISTORY OF PRESENT ILLNESS: This is an 87-year-old male withan extensive medical history presented to the EmergencyDepartment on [**2192-3-25**] complaining of right lower quadrant
abdominal pain
DISEASE
since 2 a.m. Patient states that the
pain
DISEASE
wasnonradiating. He also complained of
dry heaves
DISEASE
without any
emesis
DISEASE
or
diarrhea
DISEASE
. He did not report any
fevers
DISEASE
or
chills
DISEASE
.He states that his fingersticks are within normal limits inthe 150s. He does not report any
weight gain
DISEASE
or loss. Hestates that he has had similar episodes of right lowerquadrant
pain
DISEASE
which had been due to elevated lactate levelsand
acidosis
DISEASE
and he had been treated conservatively in thepast.CT scan of the abdomen which was done in the Emergency Roomon the date of admission showed dilated appendix concerningfor
acute appendicitis
DISEASE
. Given the patient's extensivemedical history specifically his cardiac risk factors thedecision was made to conservatively treat the patient withintravenous antibiotics.PAST MEDICAL HISTORY:1.
Atrial fibrillation
DISEASE
with DDI pacer.2. Noninsulin-dependent
diabetes mellitus
DISEASE
.3. Status post coronary artery bypass graft times three in[**2181**].4. Nephrolithiasis.5. History of
colon cancer
DISEASE
.6. Status post episode of
bowel ischemia
DISEASE
.7. End-stage
cardiomyopathy
DISEASE
with ejection fraction 20 to 30%with
mitral regurgitation
DISEASE
and
tricuspid regurgitation
DISEASE
.8. Chronic
renal insufficiency
DISEASE
with a baseline creatinine of1.6.PAST SURGICAL HISTORY:1. Status post coronary artery bypass graft times three in[**2181**].2. Sigmoid colectomy in [**2167**].ALLERGIES: Penicillin.MEDICATIONS:1. Glyburide.2. Coumadin.3. Neurontin 100 mg p.o. t.i.d.4. Aspirin 81 mg p.o. q. day.5. Lisinopril 5 mg p.o. q.d.6. Digoxin 0.125 mg p.o. q.d.7. Allopurinol 200 mg p.o. q.d.8. Bumex.9. Carvedilol 12.5 mg p.o. b.i.d.10. Zantac 150 mg p.o. b.i.d.PHYSICAL EXAMINATION UPON EVALUATION: Temperature of 99.2heart rate 72 respiratory rate 24 blood pressure 133/55oxygen saturation 95% on room air. He is ill appearing butin no acute distress. He is alert and oriented times three.His sclerae are anicteric and his neck is supple without anymasses. His lungs have bibasilar crackles. His heart is aregular rate and rhythm with a
II/VI holosystolic murmur
DISEASE
.His abdomen is nondistended and has normoactive bowel sounds.The abdomen is soft and tender in the right lower quadrantwith guarding and rebound. His extremities are arm and have1Admission Date: [**2192-3-25**] Discharge Date: [**2192-4-1**]Service:HISTORY OF PRESENT ILLNESS: The patient is an 87-year-oldgentleman with
coronary artery disease
DISEASE
status post coronaryartery bypass graft end-stage
ischemic cardiomyopathy
DISEASE
diabetes mellitus
DISEASE
and
atrial fibrillation
DISEASE
status post VVIrecently admitted for
ischemic colitis
DISEASE
treated with fluids.The patient was last admitted in [**11-14**] with
congestive heart
failure
DISEASE
exacerbation and then discharged after treatment withLasix and Natrecor. On this admission the patient wasinitially admitted to the surgical service on [**2192-3-25**] withtwo days of right lower quadrant
pain
DISEASE
that was concerning for
appendicitis
DISEASE
. The patient was treated conservatively withlevofloxacin and Flagyl and the
abdominal pain
DISEASE
improved. Thepatient was transferred to the [**Hospital Unit Name 196**] Service on [**2192-3-29**] forelectrophysiology procedure of changing his pacemaker to abiventricular pacemaker.PAST MEDICAL HISTORY:
Atrial fibrillation
DISEASE
status post VVIpacemaker.Non-insulin-dependent
diabetes mellitus
DISEASE
.Three-vessel CABG in [**2181**].
Nephrolithiasis
DISEASE
.History of
colon cancer
DISEASE
.Status post partial resection of the bowel.History of an episode of
bowel ischemia
DISEASE
.End-stage
cardiomyopathy
DISEASE
ejection fraction estimated at 30percent.
Chronic renal insufficiency
DISEASE
.ALLERGIES: PENICILLIN UNKNOWN REACTION.MEDICATIONS: At home1. Glyburide.2. Coumadin.3. Neurontin.4. ASA 81 mg q.d.5. Lisinopril unknown dose.6. Digoxin unknown dose.7. Allopurinol.8. Bumex unknown dose.9. Carvedilol unknown dose.PHYSICAL EXAMINATION: Upon transfer to the [**Hospital Unit Name 196**] Servicetemperature 98.1 degrees blood pressure 123/60 heart rate70. An elderly gentleman in no apparent distress. Skin examnotable for moles. No jugular venous distension in the neck.Heart: Irregularly irregular rhythm S1 and S2. Lungs:Clear to auscultation. Extremities: No
edema
DISEASE
good pulsesthroughout. Neurologic: Alert and oriented conversantappropriate 5/5 strength.LABORATORY DATA: Within normal limits.CONCISE SUMMARY OF HOSPITAL COURSE: The patient is an 87-year-old gentleman with
coronary artery disease
DISEASE
status postcoronary artery bypass graft
ischemic cardiomyopathy
DISEASE
diabetes mellitus
DISEASE
and
atrial fibrillation
DISEASE
status post VVI inthe past. The patient was initially admitted to the SurgicalService for right lower quadrant
pain
DISEASE
however treatedconservatively with resolution. The patient was nowtransferred to the [**Hospital Unit Name 196**] Service on [**2192-3-29**] for pacemakerchange to a biventricular pacer.PROBLEM LIST:1. [**Name2 (NI) 4957**]y: The patient underwent
biventricular
pacer placement
DISEASE
on [**2192-3-30**] after his INR was less than 1.8. The patient tolerated the procedure well. The patient was treated with prophylactic antibiotics for skin flora with five doses of clindamycin given the patient's penicillin allergy for a total five-day course. The patient did well with a new biventricular pacemaker and was discharged home with plans to follow up with Dr. [**Last Name (STitle) **].1.
Coronary artery disease
DISEASE
: The patient is status post CABG in the past. The patient was without symptoms in the hospital and continued on his carvedilol dose. The patient's aspirin was restarted after pacemaker placement.1. Pump: Ejection fraction of 30 percent. The patient had his pacemaker changed to a biventricular pacemaker. The patient continued on lisinopril and digoxin. The patient was clinically without signs of
overload
DISEASE
throughout his hospital stay.1.
Atrial fibrillation
DISEASE
: The patient's Coumadin was restarted after his pacemaker change procedure.1.
Abdominal pain
DISEASE
: Resolved was likely
ischemic colitis
DISEASE
versus mild
inflammation
DISEASE
that resolved with antibiotics. The patient was continued on levofloxacin and Flagyl for approximately a one-week course.1.
UTI
DISEASE
: The patient with
methicillin-sensitive enterococcus
DISEASE
on urine culture and treated with nitrofurantoin.1.
Chronic renal insufficiency
DISEASE
. The patient's creatinine was at baseline and remained at baseline throughout his hospital stay.1.
Diabetes mellitus
DISEASE
type 2: The patient was maintained on his insulin sliding scale and fingersticks were within normal limits. The patient's glyburide was restarted prior to discharge.CODE STATUS: The patient was full code as discussed andconfirmed with the patient.DISCHARGE CONDITION: Stable.DISCHARGE STATUS: Home with services.DISCHARGE DIAGNOSES:
Abdominal pain
DISEASE
.
Coronary artery disease
DISEASE
.
Congestive heart failure
DISEASE
.
Diabetes mellitus
DISEASE
.
Urinary tract infection
DISEASE
.Biventricular pacemaker placement.DISCHARGE MEDICATIONS:1. Lisinopril 5 mg q.h.s.2. Carvedilol 12.5 mg b.i.d.3. Bumetanide 1 mg q.d.4. Allopurinol 200 mg q.d.5. Digoxin 0.125 mg q.d.6. Gabapentin 100 mg t.i.d.7. Ranitidine 150 mg q.d.8. Aspirin 81 mg q.d.9. Clindamycin 300 mg q.i.d. for 3 additional days.10. Nitrofurantoin 100 mg q.i.d. for 5 days.11. Glyburide 5 mg q.d.12. Coumadin as instructed.FOLLOW UP: Patient to follow up with Dr. [**Last Name (STitle) **] as wellas Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as well as his primary care physician. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **] [**MD Number(1) 4958**]Dictated By:[**Last Name (NamePattern1) 4959**]MEDQUIST36D: [**2192-7-24**] 15:13:27T: [**2192-7-25**] 08:13:26Job#: [**Job Number 4960**]Admission Date: [**2178-12-5**] Discharge Date: [**2178-12-21**]Date of Birth: [**2114-2-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:Doxepin / Levofloxacin / OxycontinAttending:[**First Name3 (LF) 287**]Chief Complaint:
sepsis
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:64 year-old gentleman with history of
lung cancer
DISEASE
s/p rightpneumonectomy in [**2174**] severe
COPD
DISEASE
recently discharged from[**Hospital1 18**] MICU [**2178-12-2**] s/p tracheostomy and [**Month/Day/Year 282**] placement afteradmission for
respiratory failure
DISEASE
due to
pneumonia
DISEASE
nowre-admitted to [**Hospital1 18**] with
fever hypotension
DISEASE
.On last admission patient unabled to be weaned from theventilator. After tracheostomy and [**Hospital1 282**] tube placement he wasdischarged to [**Hospital1 **] on [**2178-12-2**] for vent weaning. While therewas
constipated
DISEASE
according to wife. On [**2178-12-4**] patient becameagitated and
hypotensive
DISEASE
to 82/58 and transferred back to [**Hospital1 18**]ED.On presentation to the [**Hospital1 18**] ED he was found to be
hypotensive
DISEASE
to 64/56 tachycardic to 120
febrile
DISEASE
to 102.8F and agitated.Patient had several large
loose bowel movements
DISEASE
in the ED. Alsofound to have a drop in hct from 27.8 on arrival to ED to 22.9on repeat draw one hour later. (Hct 26.9 on discharge.)Of note femoral line attempted at [**Hospital1 **] but unsuccessful dueto patient's
agitation
DISEASE
.In the [**Last Name (LF) **] [**First Name3 (LF) **] attempt at IJ central line placement wasunsuccessful. A femoral central intravenous catheter wasplaced. He was given IVF and started on Neosynephrine for bloodpressure support with good response. He received a total of 4Liters of normal saline flagyl 500mg IV x1 vancomycin 1 gramIV x1 ceftriaxone 1gram IV x1 2U PRBC.Past Medical History:1.
Squamous cell lung carcinoma
DISEASE
status post rightpneumonectomy in [**2174**].2.
Prostate cancer
DISEASE
status post radical prostatectomy.3. Perioperative
pulmonary embolus
DISEASE
[**2174**].4.
Type 2 diabetes mellitus
DISEASE
.5.
Chronic obstructive pulmonary disease
DISEASE
.6.
Atrial fibrillation
DISEASE
.7. Transient ischemic attack in [**2165**].8.
Gout
DISEASE
.9. Atypical
chest pain
DISEASE
since [**2164**].10.
Gastroesophageal reflux disease
DISEASE
.11.
Obstructive sleep apnea
DISEASE
. unable to tolerate BiPAP.12.
Hypertension
DISEASE
.13.
Colonic polyps
DISEASE
.14.
Hypercholesterolemia
DISEASE
.15.
Basal cell carcinoma
DISEASE
on his back.16.
Anxiety
DISEASE
.17. Sciatica.18. History of
herpes zoster
DISEASE
.19. multiple admissions for
pneumonia
DISEASE
(including pseudomonas)and
bronchitis
DISEASE
last in [**10-31**] resulting in ventilatordependence trach and [**Date Range 282**] placement20. vitamin B12 deficiency.21.
Diastolic heart failure
DISEASE
. Echo [**7-31**]: LVEFAdmission Date: [**2196-4-15**] Discharge Date: [**2196-4-21**]Service: MEDICINE
Allergies
DISEASE
:Penicillins / Amiodarone HclAttending:[**First Name3 (LF) 800**]Chief Complaint:dark stoolsMajor Surgical or Invasive Procedure:EGD on [**2196-4-16**]Capsule Study [**2196-4-18**]History of Present Illness:Mr. [**Known lastname 4924**] is a [**Age over 90 **] year-old man with a history of coronaryarteryd disease
diabetes hypertension
DISEASE
ischemic/radiation
proctitis
DISEASE
and
colon cancer
DISEASE
who presents with a
GIB
DISEASE
..Two recent admission. The first ([**3-17**] - [**3-25**]) was for a lower GI
bleed
DISEASE
. A colonoscopy was notable for stigmata of a recent
internal hemorrhoid bleed
DISEASE
with post
radiation proctitis
DISEASE
..Then readmitted ([**4-5**] - [**4-11**]) this time with lower extremity
edema
DISEASE
thought to be secondary to a
CHF
DISEASE
exacerbation. He wasdiuresed 18 liters of fluid via Lasix gtt and Diuril with a dryweight of 68.5kg achieved..Since discharge from hospital has been relatively stable thoughhas been less active (previously could do 30 minutes on thetreadmill daily but now cannot do any). Over the last day hereports approximately 10 hours of dark black stools. This hasnot been associated with any
abdominal pains nausea/vomiting
DISEASE
chest pains shortness
DISEASE
of breath fevers/chills. He called PCPand was advised to come to ED..In the ED initial vitals showed T 97.9 HR 70 BP 122/42 100%
RA
DISEASE
. His hematocrit was noted to be 22 down from mid 33 justfour days prior. One liter of NS was given and unit of blood washung. Protonix IV was also given..Past Medical History:1.
Coronary artery disease
DISEASE
- CABG ([**5-/2181**]) with LIMA to LAD SVG to PDA SVG to OM3- Cath ([**1-/2187**]) with 20% LM native 3VD and patent LIMA to LAD andSVG to OM3. Occluded SVG to the PDA.2.
Congestive heart failure
DISEASE
- Echo ([**3-19**]) with EF 40% (secondary to dyskinesis of the basalinferior and posterior (inferolateral) walls and mild
LVH
DISEASE
3.
Mitral regurgitation
DISEASE
(3Admission Date: [**2197-5-9**] Discharge Date: [**2197-5-13**]Service: MEDICINE
Allergies
DISEASE
:Penicillins / Amiodarone HclAttending:[**First Name3 (LF) 905**]Chief Complaint:bright red blood per
rectum weakness
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:History of Present Illness: [**Age over 90 **] year old male with medicalhistory pertinent for CAD Chronic
Systolic CHF CKD
DISEASE
and DM whopresents with lower GI bleed. Patient began to feel ill and weakyesterday evening and began to have
diarrhea
DISEASE
.
Diarrhea
DISEASE
was notedto be mixed with bright red blood. He thinks that he had Admission Date: [**2198-9-20**] Discharge Date: [**2198-9-23**]Service: MEDICINE
Allergies
DISEASE
:Penicillins / Amiodarone HclAttending:[**First Name3 (LF) 425**]Chief Complaint:
PEA arrest
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:History was obtained from his son and [**Name (NI) **] records:Mr. [**Known lastname 4924**] is a [**Age over 90 **] year old male with a PMH significant forsevere
MR ischemic cardiomyopathy
DISEASE
with severe left ventriculardysfunction with an EF of 30% in [**2197-2-12**]
NSVT
DISEASE
and a historyof
ischemic bowel
DISEASE
due to overdiuresis. He was in his usualstate of health until a few days ago when he started feelingvery weak and fatigued..His son went to pick him up tonight and as they were walkingtoward the car he became fatigued and weak to the point wherehe wanted to go back in the house. They turned around and asthey were walking toward the house he progressively becameweaker to the point where his son had to carry him and lay himon a bench. They called EMS and between the time that theycalled EMS and their arrival (Admission Date: [**2140-5-27**] Discharge Date: [**2140-6-2**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 45**]Chief Complaint:Back and leg
pain
DISEASE
Major Surgical or Invasive Procedure:[**2140-5-27**] [**Doctor Last Name 1352**] L3-5 PSIF LamiHistory of Present Illness:[**5-27**] [**Doctor Last Name 1352**][**5-27**] L3-5 PSIF Lami 600 EBLHPI: [**Age over 90 **] F L4-L5
spondylolisthesis
DISEASE
with mild stenosis atL3-4 L4-5 and L5-S1 R leg
pain
DISEASE
amb with walkerPMH: Angina HTN Cholesterol Skin
Cancer
DISEASE
Insomnia OA
Restless leg syndrome
DISEASE
osteoperosisMED: Fosamx 70 Atenlol 25 Aspirin 325 Nitro 0.6 mg SLlipitor 10 Gabapentin 100 [**Hospital1 **] Tramadol 50 Triamterene-HCTZ37.5-25 Calcium 500-vitD
MVI
DISEASE
ALL
DISEASE
: NKDASocial History:she lives alone in [**Location (un) 3320**]. No tobacco or alcohol use. Has foursons two of whom live close by.Family History:No
premature CAD SCD
DISEASE
Physical Exam:RLE painBLE fires L2-S1 motorRepsonds to senstion throughout BLEVitals: TEMP 97.1 HR 83 BP 124/68 RR 23 SAT 96% 3L NCGen: Pleasant well appearing elderly woman lying in bed in NADEyes: No
conjunctival pallor
DISEASE
. No
icterus
DISEASE
.ENT: MMM. OP clear.CV: JVP low. Normal carotid upstroke without
bruits
DISEASE
. PMI in 5thintercostal space mid clavicular line. RR. nl S1 S2. Nomurmurs rubs clicks or gallops. Full distal pulsesbilaterally. No
femoral bruits
DISEASE
.LUNGS: LAdmission Date: [**2140-8-11**] Discharge Date: [**2140-8-20**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4980**]Chief Complaint:Surgical Wound DrainingMajor Surgical or Invasive Procedure:Debridement of Laminectomy WoundHistory of Present Illness:Ms. [**Known lastname 4643**] is a [**Age over 90 **] year woman with a h/o CAD
HTN CHF
DISEASE
with EFof 25% s/p L4-L5 laminectomy with Dr. [**Last Name (STitle) 1352**] in [**5-/2140**]presented from rehab facility with nonhealing lumbar surgicalwound. Wound began producing serous drainage a week prior topresentation and started on Keflex [**8-6**]. Drainage was culturedon [**8-6**] which grew heavy growth of MSSA and moderate alpha
strep
DISEASE
as a result was switched to Levaquin on [**8-8**] thentransferred to [**Hospital1 18**] [**8-11**].Past Medical History:s/p L4-5 laminectomy/fusionCAD
HTN
DISEASE
Hyperlipidemia
DISEASE
Osteoporosis
DISEASE
Osteoarthritis
DISEASE
Skin
Cancer
DISEASE
Restless leg syndrome
DISEASE
Social History:She lives alone in [**Location (un) 3320**]. No tobacco or alcohol use. Has foursons two of whom live close by.Family History:No
premature CAD SCD
DISEASE
Physical Exam:O: Tm:98.1 BP:115/64 HR:78 RR:18 SpO2:97% on
RA
DISEASE
General: Alert oriented to Person and Place no acute distressHEENT: Sclera anicteric MMM oropharynx clearNeck: supple no LADLungs: Fine crackles on BL lung bases no wheezes ronchiCV: Regular rate and rhythmAbdomen: soft non-tender non-distended bowel sounds presentno rebound
tenderness
DISEASE
or guarding no
organomegaly
DISEASE
GU: foley draining clear yellow urineExt: warm well perfused 2Admission Date: [**2167-4-28**] Discharge Date: [**2167-5-3**]Date of Birth: [**2090-2-1**] Sex: FService: GEN [**Doctor First Name 147**]ADMITTING DIAGNOSIS:1. Pancreatic mass.DISCHARGE DIAGNOSES:1. Pancreatic mass.PROCEDURES DURING ADMISSION:1. Exploratory laparotomy lysis of
adhesions
DISEASE
andenucleation of a neuro-endocrine pancreatic mass.HISTORY OF PRESENT ILLNESS: The patient is a 77 year oldfemale who presents with a history of a benign pancreaticmass which causes her significant
abdominal pain
DISEASE
. Thepatient presents electively to have this resected.PAST MEDICAL HISTORY:1.
Diabetes mellitus
DISEASE
.2. Increased cholesterol.3. Idiopathic
hypertrophic subaortic stenosis
DISEASE
with anechocardiogram [**3-/2167**] revealing an ejection fraction ofgreater than 55%.PAST SURGICAL HISTORY:1. Pancreatic resection in [**2155**].ALLERGIES: No known
drug allergies
DISEASE
.MEDICATIONS:1. Aspirin.2. Atenolol 125 mg p.o. twice a day.3. Hydrochlorothiazide 25 mg p.o. q. day.4. Zestril 40 mg p.o. q. day.5. Prilosec 20 mg p.o. q. day.6. Verapamil 240 mg p.o. twice a day.PHYSICAL EXAMINATION: On examination the patient is awakeand alert in no apparent distress. Her heart is regular rateand rhythm S1 S2. Her lungs are clear to auscultationbilaterally. Abdomen soft. She has a well healed midlinescar.HOSPITAL COURSE: The patient was admitted to the hospitalon [**2167-4-28**] and taken to the Operating Room forenucleation of the pancreatic mass and lysis of
adhesions
DISEASE
.The patient tolerated the procedure well however in thePost Anesthesia Care Unit she was noted to be extremelysomnolent. A blood gas revealed a pCO2 of 104. The patientwas followed closely. Given the fact that her blood gasesdid not improve and it was thought that she had beenover-narcotized the patient was electively intubated andtransferred to the Intensive Care Unit for furthermonitoring.She remained hemodynamically stable the this event howeverher pH was significantly decreased running from 7.04 to 7.1.The patient's course in the Surgical Intensive Care Unit wasonly notable for a transient rise in her liver functiontests. These however slowly trended down.The patient was extubated and her respiratory status remainedgood. She was started on her outpatient cardiac medications.Her diet was fully advanced.On [**2167-5-1**] the patient was transferred from the IntensiveCare Unit to the floor with intensive pulmonary toilet. Herdiet was advanced. A drain amylase was checked and revealeda value of 3724. Value was rechecked. This value trendeddown however given the fact that the patient was stableher diet was advanced. She was tolerating p.o.It was decided that she would be discharged home on herpreoperative medications on [**2167-5-3**] in stable condition.She would also be discharged on:DISCHARGE MEDICATIONS:1. Protonix 40 mg p.o. q. day.DISCHARGE INSTRUCTIONS:1. She was told to follow-up with Dr. [**Last Name (STitle) 468**] in the officeand to call for a follow-up appointment. [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] M.D. [**MD Number(1) 4984**]Dictated By:[**Last Name (NamePattern1) 4985**]MEDQUIST36D: [**2167-5-2**] 13:21T: [**2167-5-2**] 16:01JOB#: [**Job Number 4986**]Admission Date: [**2168-10-4**] Discharge Date: [**2168-10-8**]Date of Birth: [**2090-2-1**] Sex: FService: CCUHISTORY OF PRESENT ILLNESS: Patient is a 78-year-old femalewith a history of
type 2 diabetes hypertension
DISEASE
hypercholesterolemia
DISEASE
and
hypertrophic obstructive
DISEASE
cardiomyopathy
DISEASE
who presents for ethanol septal ablation.Her
hypertrophic cardiomyopathy
DISEASE
was first discoveredapproximately 2.5 years prior to admission during apreoperative evaluation for her pancreatic surgery. Sincethen she has noticed increasing
dyspnea
DISEASE
on exertion andlower extremity
edema
DISEASE
.PAST MEDICAL HISTORY:1.
Hypertrophic obstructive cardiomyopathy
DISEASE
with a restinggradient of 90.2. Type 2
diabetes
DISEASE
diet controlled.3.
Hypertension
DISEASE
.4.
Hypercholesterolemia
DISEASE
.5.
Coronary artery disease
DISEASE
.6.
Chronic renal insufficiency
DISEASE
with a baseline creatinine of1.6.7. Moderate-to-severe
pulmonary hypertension
DISEASE
.8. Status post pancreatic resection in [**2155**].9. Status post pancreatic enucleation and resection for a
neuroendocrine tumor
DISEASE
.10. GERD.MEDICATIONS ON ADMISSION:1. Lisinopril 20 mg p.o. q.d.2. Atenolol 50 mg p.o. b.i.d.3. Lasix 20 mg p.o. q.d.4. Clonidine 0.1 mg p.o. b.i.d.5. Aspirin 81 mg p.o. q.d.6. Multivitamins.ALLERGIES: No known
drug allergies
DISEASE
.SOCIAL HISTORY: The patient is a Russian speaking female.She is retired and formally worked as a secretary. She ismarried and has one daughter. She denies any history ofalcohol use or smoking.FAMILY HISTORY: Her mother had [**Name (NI) 2481**] disease. Herfather died from
peritonitis
DISEASE
.PHYSICAL EXAM ON ADMISSION: Temperature of 96.0 bloodpressure of 154/65 heart rate of 51 respiratory rate of 17and oxygen saturation 98% on 4 liters nasal cannula.Physical exam is notable for a 2/6 systolic ejection murmurbest heard at the left sternal border. The remainder of herexamination was normal.LABORATORIES: Notable for a creatinine of 1.6.HOSPITAL COURSE: The patient was admitted for ethanol septalablation for symptomatic
hypertrophic obstructive
DISEASE
cardiomyopathy
DISEASE
. The second septal perforator was ablated andher gradient decreased from 90 to 5-10 mm Hg. The patienttolerated the procedure well. For blood pressure controlthe patient received metoprolol and captopril. Initiallythe patient required nitroglycerin drip for blood pressurecontrol and eventually she was weaned off of it and startedon diltiazem extended release. At the time of discharge herblood pressures were ranging from 120-140. The patientremained on a temporary pacemaker following septal ablationdue to the risk of complete
heart block
DISEASE
.Following 48 hours this temporary pacemaker was removedsince the patient had remained in sinus rhythm. Anechocardiogram performed following the procedure showed animprovement of her left ventricular outflow tract gradient aswell as improvement of the severity of her mitralregurgitation. Left ventricular function with the exceptionof the basal septum remained vigorous throughout.The patient had a brief episode of
delirium
DISEASE
following theprocedure which was resolving by the time of discharge. Hercreatinine also slightly elevated from 1.6 to 1.9 thatremained stable and was felt to be within her normal range.Her
diabetes
DISEASE
was well controlled with regular insulin-slidingscale.She did have some mild
pulmonary edema
DISEASE
and was given Lasixprn.CONDITION ON DISCHARGE: Stable.DISCHARGE STATUS: Patient is discharged to home. Sherequires no home services.DISCHARGE DIAGNOSES:1.
Hypertrophic obstructive cardiomyopathy
DISEASE
status postethanol septal ablation.2.
Diastolic heart failure
DISEASE
.3.
Chronic renal insufficiency
DISEASE
.4.
Hypertension
DISEASE
.5.
Coronary artery disease
DISEASE
.7.
Hypercholesterolemia
DISEASE
.8.
Gastroesophageal reflux disease
DISEASE
.9.
Pulmonary hypertension
DISEASE
.DISCHARGE MEDICATIONS:1. Aspirin 325 mg p.o. q.d.2. Atorvastatin 10 mg p.o. q.d.3. Diltiazem sustained release 120 mg p.o. q.d.4. Toprol XL 150 mg p.o. q.d.5. Lisinopril 40 mg p.o. q.d.6. Pantoprazole 40 mg p.o. q.d.7. Furosemide 20 mg p.o. q.d.8. Multivitamin one p.o. q.d.FOLLOW-UP PLANS: The patient is scheduled to followup withher cardiologist Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**]. She is also due to bescheduled for an outpatient MRI of her kidneys looking for
renal artery stenosis
DISEASE
. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**] M.D. [**MD Number(1) 4992**]Dictated By:[**Name8 (MD) 4993**]MEDQUIST36D: [**2168-10-10**] 14:14T: [**2168-10-11**] 08:24JOB#: [**Job Number 4994**]Admission Date: [**2169-6-22**] Discharge Date: [**2169-6-29**]Date of Birth: [**2090-2-1**] Sex: FService: [**Doctor First Name 147**]
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 4995**]Chief Complaint:right colon massMajor Surgical or Invasive Procedure:right colectomyHistory of Present Illness:Patient is a 79 year old Russian speaking female with history of
cardiopulmonary disease
DISEASE
diagnosed with
adenocarcinoma of the
right colon
DISEASE
in [**2169-5-18**].Past Medical History:1.
hypertension
DISEASE
2.
diabetes type II
DISEASE
3.
hypercholesterolemia
DISEASE
4.
coronary artery disease
DISEASE
5.
chronic renal failure
DISEASE
6.pulmonary hypertension-7.left ventricle outflow tract obstructiondiastolic heartfailure-ejection fraction of 70%8.
gastro-esophageal reflux disease
DISEASE
pancreatic resection [**2155**] [**2166**]- required intubation withhistory of
delirium
DISEASE
resection of neuroendocrine
tumor
DISEASE
septal ablation [**2164**]Social History:positive for tobacco negative for alcohol and recreation druguse.Family History:non-pertinantPhysical Exam:On discharge patient is afebrile with stable vitals. Abodomenis soft and non tender on exam. Abdominal incision has noevidence of
infection
DISEASE
and staples are in place.Pertinent Results:[**2169-6-22**] 06:59PM TYPE-MIX PO2-42* PCO2-50* PH-7.27* TOTALCO2-24 BASE XS--4[**2169-6-22**] 06:59PM O2 SAT-70[**2169-6-22**] 06:58PM TYPE-ART TEMP-37.5 RATES-[**10-23**] TIDAL VOL-500PEEP-8 O2-40 PO2-117* PCO2-43 PH-7.33* TOTAL CO2-24 BASE XS--3INTUBATED-INTUBATED[**2169-6-22**] 06:45PM WBC-9.7 RBC-3.73* HGB-11.8* HCT-35.0* MCV-94MCH-31.5 MCHC-33.6 RDW-13.4[**2169-6-22**] 02:55PM TYPE-ART PO2-82* PCO2-43 PH-7.29* TOTALCO2-22 BASE XS--5[**2169-6-22**] 02:55PM HGB-11.3* calcHCT-34[**2169-6-22**] 01:49PM HCT-29.6*[**2169-6-22**] 12:43PM TYPE-ART PO2-96 PCO2-45 PH-7.25* TOTAL CO2-21BASE XS--7[**2169-6-22**] 11:47AM TYPE-ART PO2-97 PCO2-53* PH-7.22* TOTALCO2-23 BASE XS--6 INTUBATED-INTUBATED[**2169-6-22**] 11:22AM WBC-13.9*# RBC-3.92* HGB-12.4 HCT-36.1 MCV-92MCH-31.6 MCHC-34.4 RDW-13.2Brief Hospital Course:Patient was taken to the operating room on [**2169-6-22**] forthe above stated procedure. The patient was hemodynamicallystable throughout the operation requiring a small amout ofpressors. She was then admitted to the intensive care unitpost-operatively intubated and monitored with a swan cathaterthat was placed intraoperatively. Rising pulmonary arterypressures were noted- 60/30's. Patient [**Last Name (un) 4996**] a course ofkefzol/flagyl which was continued for 2 days. On postoperative day 1 the patient was extubated and remained nothingby mouth. On post operative day 2 patient experienced
shortness
DISEASE
of breath satting 89% on 2 liters. Intra-venous fluids weredecreased from 100 cc per hour to 80 than 50cc and remained on[**1-19**] liters oxygen. Patient was noted to have good urinary outputof 90-
100cc
DISEASE
per hour. On post operative day 2 intra-venousfluids were dereased to 30 cc per hour oxygen saturationremained good on 3 liters and urinary output was also adequateand she was transferred to the floor and advanced to clears. Onpost-operative day 4 patient tolerated clears. Onpost-operative day 5 patient was noted to be slightly distendedand was made nothing by mouth. On post-operative day 6 patientreported to pass flatus clears were advance and she wasevalutated by physical therapy. Home physical therapy wasreccommended. Also on post-operative day 5 family noted someacute mental status changes she was seen by neurology. Onpost-operative day 6 mental status was noted to have greatlyimproved per family futher neuro workup was deferred tooutpatient. Patient was discharged on post-operative day 7 withhome services.Medications on Admission:lasixcarduratoprolariceptlisinoprillipitorDischarge Medications:not requiring narcoticsDischarge Disposition:Home With ServiceFacility:[**Hospital1 **] Family & [**Hospital1 1926**] ServicesDischarge Diagnosis:
adenocarcinoma of the right colon
DISEASE
Discharge Condition:goodDischarge Instructions:Do not soak incisions in [**Last Name (LF) 4997**] [**First Name3 (LF) **] shower and then pat incisionline
dry
DISEASE
.
Resume
DISEASE
prehospital medications.[**Month (only) 116**] take tylenol for
pain
DISEASE
.Followup Instructions:Patient is to call and make appointment to be by Dr. [**Last Name (STitle) 1888**] in[**11-18**] weeks.Please follow up with neurologist.Admission Date: [**2171-12-2**] Discharge Date: [**2171-12-21**]Date of Birth: [**2090-2-1**] Sex: FService: MEDICINE
Allergies
DISEASE
:NitroglycerinAttending:[**First Name3 (LF) 1145**]Chief Complaint:
Shortness of breath
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:The patient is an 81 year old Russian-speaking female with ahistory of
HOCM
DISEASE
s/p septal EtOH ablation in [**2167**]
CHF
DISEASE
EF Admission Date: [**2104-10-7**] Discharge Date: [**2104-10-20**]Date of Birth: [**2046-8-21**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 1505**]Chief Complaint:Transferred from OSH for management of CAD PCI vs CABGMajor Surgical or Invasive Procedure:[**10-15**] CABG x 4History of Present Illness:This is a 58 year old male with a history of
hypertension
DISEASE
typeII DM
hyperlipidemia chronic renal insufficiency
DISEASE
and
polysubstance abuse
DISEASE
who presents from an OSH s/p cardiac cathfor further management of his
coronary disease
DISEASE
. Per report from[**Hospital6 5016**] Mr. [**Known lastname **] was admitted on [**2104-9-30**] withepigastric discomfort that subsequently developed into chest
pain
DISEASE
radiating to the jaw and left shoulder. Per the patient hehas been having
intermittent abdominal pain
DISEASE
associated with
nausea
DISEASE
and vomitting for approximately 2.5 weeks to 1 month. The
abdominal pain
DISEASE
is in the epigastrium not associated with eatingor with position and is
non-radiating
DISEASE
. The
abdominal pain
DISEASE
hasresolved since being in the hospital..On the evening of [**2104-9-30**] he reports that his
abdominal pain
DISEASE
was accompanied by 8 out of 10 substernal
chest pain
DISEASE
. The chest
pain
DISEASE
radiated to his jaw and left shoulder. This
pain
DISEASE
lasted forapproximately 1 hour and resolved in the ED at [**Hospital3 **]. Hedoes not recall precipitating factors for this
chest pain
DISEASE
. Butdoes report that his roommate informed him that he had Admission Date: [**2179-2-1**] Discharge Date: [**2179-2-8**]Date of Birth: [**2114-2-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:Doxepin / Levofloxacin / OxycontinAttending:[**Last Name (NamePattern4) 290**]Chief Complaint:
chest pain
DISEASE
Major Surgical or Invasive Procedure:stenting of SVCHistory of Present Illness:64 yo man with h/o lung CA s/p R pneumonectomy severe
COPD
DISEASE
with prolonged
respiratory failure
DISEASE
requiring prolonged trach (2months ago) wean presents from rehab with increased bilateralupper extremety
edema
DISEASE
(present since [**10-31**] admission) and leftsided
chest pain
DISEASE
for 2 days(continuous for about 20hrs). Patientdenies any
fevers chills cough
DISEASE
radiation diaphoeris nosimilar
pain
DISEASE
in past no pleuritic nature n/v/diaphoresis. Noassociated triggers or change with positions no
pain
DISEASE
currently.He had been doing well at rehab this past week after ativan andvalium were stopped and started on haldol with good relief.Past Medical History:1.
Squamous cell lung carcinoma
DISEASE
status post rightpneumonectomy in [**2174**].2.
Prostate cancer
DISEASE
status post radical prostatectomy.3. Perioperative
pulmonary embolus
DISEASE
[**2174**].4.
Type 2 diabetes mellitus
DISEASE
.5.
Chronic obstructive pulmonary disease
DISEASE
.6.
Atrial fibrillation
DISEASE
.7. Transient ischemic attack in [**2165**].8.
Gout
DISEASE
.9. Atypical
chest pain
DISEASE
since [**2164**].10.
Gastroesophageal reflux disease
DISEASE
.11.
Obstructive sleep apnea
DISEASE
. unable to tolerate BiPAP.12.
Hypertension
DISEASE
.13.
Colonic polyps
DISEASE
.14.
Hypercholesterolemia
DISEASE
.15.
Basal cell carcinoma
DISEASE
on his back.16.
Anxiety
DISEASE
.17. Sciatica.18. History of
herpes zoster
DISEASE
.19. multiple admissions for
pneumonia
DISEASE
(including pseudomonas)and
bronchitis
DISEASE
last in [**10-31**] resulting in ventilatordependence trach and [**Date Range 282**] placement20. vitamin B12 deficiency.21.
Diastolic heart failure
DISEASE
. Echo [**7-31**]: LVEFAdmission Date: [**2152-11-25**] Discharge Date: [**2152-12-2**]Date of Birth: [**2088-1-16**] Sex: FService: NEUROLOGY
Allergies
DISEASE
:PercocetAttending:[**First Name3 (LF) 5018**]Chief Complaint:
Headache
DISEASE
&
vomiting
DISEASE
Major Surgical or Invasive Procedure:noneHistory of Present Illness:Pt is a 64 year old woman with hx of breast CA
TIA
DISEASE
's andCAD s/p CABG and R
cavernous carotid aneurysm
DISEASE
s/p clippingtransferred from [**Hospital3 **] after having been found to have
intracerebral hemorrhage
DISEASE
.Last night around 7 pm she was alone at home (lives in aretirement community) and developed
headache dizziness nausea
DISEASE
and
vomiting
DISEASE
. She also had some
diarrhea
DISEASE
and thought that shehada
viral illness
DISEASE
. Went to bed difficulty sleeping because of her
vomiting
DISEASE
. This morning she still felt dizzy and weak. Her soncame to visit her later in the morning and noted a prominent R
facial droop
DISEASE
and
slurred
DISEASE
speech. He took her to [**Hospital6 5019**] where a CT was performed that was concerning forsubarachnoid blood. She was sent to [**Hospital1 18**] for furtherevaluation.In ED repeat CT performed that showed
hypodensity
DISEASE
in R anteriorfrontal lobe c/w subacute or
acute infarct
DISEASE
with 2x2 cm
intraparenchymal hemorrage
DISEASE
in posterior portion of the
infarct
DISEASE
wtih minimal subarachnoid extension. She is admitted for furthermanagement and evaluation.ROS:Negative for recent falls head or neck
trauma
DISEASE
change in mental
status fevers
DISEASE
recent travel
rash
DISEASE
sick contacts. Pt says thattoday she feels tired and has some
unsteadiness
DISEASE
when she walks.Also thinks that her L arm is a bit weaker than the right.Past Medical History:
vertigo
DISEASE
breast CA
DISEASE
s/p chemo and radiation (per son at least 10 yearsago)
brain aneursym (R cavernous carotid) s/p
DISEASE
clipping Admission Date: [**2135-4-20**] Discharge Date: [**2135-5-9**]Date of Birth: [**2055-11-4**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 2972**]Chief Complaint:R toe
pain
DISEASE
Major Surgical or Invasive Procedure:Intubation and extubation x3History of Present Illness:79M with history of DMII CAD s/p MI
PVD COPD
DISEASE
hyperchol
HTN
DISEASE
who was admitted to the Vascular Surgery service from hiscardiologist's office with Admission Date: [**2135-8-15**] Discharge Date: [**2135-8-30**]Date of Birth: [**2055-11-4**] Sex: MService: VSUCHIEF COMPLAINT:1. Peripheral
vascular disease
DISEASE
with
claudication
DISEASE
right greater than left and right foot rest
pain
DISEASE
.2. Asymptomatic
carotid disease
DISEASE
with internal carotid artery 80 to 90% left common carotid 68 to 69% right internal carotid artery 70 to 79% with a left subclavian steel.Patient was recently hospitalized in [**Month (only) 116**] for respiratory
failure
DISEASE
and was discharged in [**2135-4-25**] and spent 2 months inrehab. He was discharged from rehab on [**2135-6-20**] to home.He returns now for carotid endarterectomy andrevascularization of the right extremity.REVIEW OF SYSTEMS: Is positive for claudication rightgreater than left x4 years now with right foot
pain
DISEASE
whichhas increased since discharge. He denies any
syncope
DISEASE
seizure amaurosis
DISEASE
or
hemiparesis seizures
DISEASE
.
Denies
DISEASE
any chest
pain
DISEASE
paroxysmal
nocturnal dyspnea orthopnea edema
DISEASE
palpitations
DISEASE
. He denies prostatism
melena
DISEASE
or bloody stools.ALLERGIES: No known
drug allergies
DISEASE
.MEDICATIONS ON ADMISSION: Included Norvasc 10 mg dailyToprol XL 100 mg daily Nexium 20 mg daily Captopril 25 mgt.i.d. Glipizide 10 mg q A.M. and Lipitor 10 mg q.d.ILLNESSES: Included
enuresis
DISEASE
status post cystoscopy withcystometrics in [**2131-3-26**]. History of coronary arterydisease with
myocardial infarction
DISEASE
x3 with a failed rightcoronary angioplasty stenting complicated by right coronarydissection requiring intra-aortic balloon support in [**2121**].
Peripheral vascular disease
DISEASE
. Left hip and
pelvic fracture
DISEASE
secondary to fall in [**2132-2-23**].
Left upper lobe cancer
DISEASE
status post right upper lobectomy with chest wall resectionmediastinal node dissection. Bronchoscopy and mediastinoscopyand scalene node biopsy in [**2132-2-23**]. History of
hypertension
DISEASE
. History of
type 2 diabetes mellitus
DISEASE
on oralagents. History of
chronic obstructive pulmonary disease
DISEASE
.History of
VRE
DISEASE
. History of
ventral hernia
DISEASE
. History of non-
Hodgkin's lymphoma
DISEASE
by scalene node biopsy. History of
ventilator-induced
DISEASE
pseudomonas
pneumonia
DISEASE
. History of
congestive heart failure
DISEASE
compensated.SOCIAL HISTORY: The patient is married x57 years. Lives withhis spouse. [**Name (NI) **] is retired. He ambulates. He is limitedsecondary to his foot
pain
DISEASE
. Patient's cardiologist is Dr.[**Last Name (STitle) **]. The patient admits to tobacco use 200 pack-years ofsmoking. He has not smoked since his lung resection in [**2132-2-23**].PHYSICAL EXAMINATION: He is alert oriented in no acutedistress. HEENT examination: No
jugular venous distension
DISEASE
.Carotids are palpable bilaterally 1Admission Date: [**2194-2-21**] Discharge Date: [**2194-3-1**]Date of Birth: [**2146-9-1**] Sex: MService: Transplant [**Doctor First Name **]HISTORY OF PRESENT ILLNESS: Patient is a 47 year-old malewith
polycystic kidney disease
DISEASE
and
impending renal failure
DISEASE
.PHYSICAL EXAMINATION: He is a well-developed male in noacute distress. He is 268 pounds with a blood pressure of133/86. Heart rate is 106. Neck is supple without masses.Heart is regular rate and rhythm with S1 and S2 clearlyheard. No murmur rub or gallop were appreciated. His lungswere clear to auscultation bilaterally. His abdomen wassoft distended and the kidneys and liver are easily palpablebilaterally. Bowel sounds are normal and present.Extremities are with 1 to 2Admission Date: [**2102-5-23**] Discharge Date: [**2102-5-26**]Date of Birth: [**2043-7-3**] Sex: MService: MEDHISTORY OF PRESENT ILLNESS: Mr. [**Name13 (STitle) 9564**] is a 58-year-old malewith
hypertension coronary artery disease
DISEASE
and AAA who wassent to the emergency department for evaluation of
hypotension
DISEASE
. The patient was seen in the primary carephysician's office on the date of admission and was found tohave a systolic blood pressure in the 70s. The patient hadbeen complaining of the
neck pain
DISEASE
over the past several weekswith radiation down his mid back. He also notes a decreasein appetite times several weeks and approximately 15-poundweight lost over the last two months. The patient denies any
abdominal pain nausea vomiting
DISEASE
or
diarrhea
DISEASE
. The patient's
last bowel movement
DISEASE
was on the day prior to admission andthere was no blood in the stool. The patient does statesthat he has been fatigued recently and has felt chilled.Although denies any
cough shortness
DISEASE
of
breath chest pain
DISEASE
or mental status changes. In the emergency department thepatient was given 4 liters of normal saline and was found tohave
hyperkalemia
DISEASE
as well as
acute renal failure
DISEASE
. Thepatient was treated with bicarbonates calcium gluconateD50 and insulin for his
hyperkalemia
DISEASE
. ABG on admissionshowed a pH of 7.14 a PCO2 of 22 PO2 of 138 and abicarbonate of 8. The patient developed
chest pain
DISEASE
followingan abdominal CT scan in the emergency department but EKGshowed no changes.
Chest pain
DISEASE
resolved spontaneously withoutintervention. The patient was given vancomycinlevofloxacin and Flagyl in the emergency department due toconcern for
sepsis
DISEASE
.PAST MEDICAL HISTORY: Coronary
artery disease
DISEASE
status post MIin [**2099**] and right coronary artery stent for a 95 percentlesion.
Hypotension
DISEASE
.
Bladder cancer
DISEASE
status post prostocystectomy in [**2091**] followedby ileoneobladder.Status post right inguinal
hernia
DISEASE
surgery in [**2102-3-23**].Left uretero-ileal anastomosis
stricture
DISEASE
.AAA with most recent scan showing an
aneurysm
DISEASE
4 cm indiameter.History of
skin cancer
DISEASE
.MEDICATIONS ON ADMISSION:1. Lisinopril 10 mg p.o. q. day2. Lopressor 25 mg p.o. b.i.d.3. Aspirin 81 mg p.o. q. day.SOCIAL HISTORY: The patient works as a bartender. He liveswith his wife. [**Name (NI) **] smokes two to three cigarettes per day andhas greater than a 100-pack-year smoking history in total.He also has one alcoholic drink per day.FAMILY HISTORY: Positive for
coronary artery disease
DISEASE
diabetes
DISEASE
and
brain cancer
DISEASE
.PHYSICAL EXAMINATION: On admission vital signs temperatureof 97.1 heart rate ranging from 96-110 blood pressureranging from 68-106/38-44 respiratory rate of 16-20 andoxygen saturation is 100 percent on 2 liters by nasalcannula. In general the patient is well appearing and in noapparent distress. HEENT: Reveals pupils equally reactiveand round to light with no sclera
icterus
DISEASE
and
dry
DISEASE
mucousmembranes. Neck shows flat JVD. Lungs are clear toauscultation anteriorly and laterally. Cardiovascular examregular rate and rhythm with no murmurs. Abdominal exam:Soft nontender and nondistended with positive bowel soundsand stool with OB negative. There is a well healing incisionin the right groin. Extremities no lower extremity
edema
DISEASE
and no rashes. Neurologic exam: Alert and oriented times 3.Cranial nerves are intact. Strength is [**4-26**] in the upper andlower extremities. There is limited range on the neckextension and full range on neck flexion. There is no point
tenderness
DISEASE
over the spine.LABORATORY DATA: On admission showed him a hematocrit of26.9 down from his baseline of 40 his potassium is elevatedat 6.6 his creatinine is elevated at 2.3 from his baseline0.9 lactate is 0.5 CK is 21 troponin is 0.05. Chest x-rayshows no
CHF
DISEASE
or infiltrate. Abdominal CT scan shows stable
abdominal aortic aneurysm
DISEASE
with no evidence of leak. Itmeasures 3.3 to 4.3 cm in diameter. There is a nonobstructing
left renal calculus
DISEASE
and there is ileal loopdiversion of the right aorta. ABG ph of 7.14 PCO2 of 22PO2 of 138 bicarbonate of 8. Renal ultrasound showed mild
hydronephrosis
DISEASE
of the right kidney and moderate
hydronephrosis
DISEASE
of the left kidney with a distended bladder.The Foley was flushed and there was no evidence of
hydronephrosis
DISEASE
following flush of the Foley and urination oftwo liters of fluid. UA shows no bacteria and 0-2 whiteblood cells with negative nitrates and negative leucocyteEstrace. Urine electrolytes showed a postive urine anion gapof 10. EKG is sinus rhythm with a rate of 65. His PRinterval is slightly prolonged at 206 millisecond. There areST elevations in V2 through V5 which purpose on previous EKGof [**2102-2-20**].HOSPITAL COURSE: Hypotension. The patient was admitted tothe MICU for evaluation of
hypotension
DISEASE
. He was started onaggressive fluid resuscitation and dopamine drip for bloodpressure management. Dopamine was eventually weaned off onthe day following admission. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test to evaluatefor
renal insufficiency
DISEASE
was within normal limits. Due toconcern for
sepsis
DISEASE
the patient was started on antibioticsalthough there was no evidence for an
infection
DISEASE
. White bloodcount was not elevated. The patient remained afebrilethroughout the remainder of the hospitalization. Nitrate waswithin normal limits. Chest x-ray was clear. UA wasnegative. All blood and urine cultures were no growth today.Because of the very low suspicion for
sepsis
DISEASE
all antibioticswere stopped on hospital day 3. With aggressive IV fluidsbecause the patient's blood pressure eventually improved backto baseline. At the time of discharge the patient'soutpatient blood pressure medications including lisinopriland metoprolol had not been started. The patient was advisedto not take these medications until he was seen by hisprimary care physician as an outpatient in one to two weeks.
Anemia
DISEASE
. The patient was admitted with hematocrit of 26.9from his baseline of 40. He was transfused four units onadmission and his hematocrits stabilized at 33. Stools wereguaiac negative and iron studies showed normal iron and lowTIBC. Abdominal CT scan showed no leak or
rupture
DISEASE
of the
abdominal aortic aneurysm
DISEASE
and there was no retroperitonealbleed.
Hemolysis
DISEASE
abs were negative. There was no evidencefor
DIC
DISEASE
. Folate was within normal limits. B12 was found tobe low and he was started on B12 supplements.Supplementation was initially through IM but it waseventually switched to p.o. as an outpatient. It is believedthat his vitamin B12 deficiency is due to the removal of histerminal ileum to make the neobladder. Now its concern thatthe patient may not be able to adequately absorb the p.o.vitamin B12 but his primary care physician will decide as anoutpatient if he should be started vitamin B12 IM injectionsinstead. The patient's hematocrit was stable at 33 at thetime of discharge.Nonanion gap
metabolic acidosis
DISEASE
. The patient's ABG onadmission was 7.14 22 138 and 8. Urine anion gap waspositive. Acidosis improved with bicarbonate drip and volumeresuscitation. Following discussion with urology it wasdetermined that neobladder obstruction was an important causefor his non anion gap
metabolic acidosis
DISEASE
. The mucosa of theilium has a tendency to excrete bicarbonate. Since thepatient neobladder had been obstructed for some time prior topresentation the patient was likely excreting large amountsof bicarbonate into his urine. With the bicarbonate drip andfluid resuscitation his bicarbonate improved closer tobaseline. At the time of discharge the patient'sbicarbonate was 18. The patient's
acidosis
DISEASE
resolved slowlythroughout the course of hospitalization.
Acute renal failure
DISEASE
. The patient was found to be in acute
renal failure
DISEASE
on hospital admission with creatinine of 2.3from his baseline of 0.9. Renal ultrasound showed bilateral
hydronephrosis
DISEASE
which immediately resolved following flushingof the Foley and removal of the mucous blood obstructing theneobladder outlets. The patient was also hydrated for
hypotension
DISEASE
which may have led to some acute tubular
necrosis
DISEASE
in addition to
obstructive renal failure
DISEASE
. At thetime of discharge the patient's creatinine was 1.2. Thepatient was encouraged to drink plenty of fluids to maintaingood oral hydration.Spinal stenosis. The patient had
complaint of neck pain
DISEASE
forseveral weeks prior to presentation. Due to concern forpossible
osteomyelitis
DISEASE
or
discitis
DISEASE
as the source of
infection
DISEASE
leading to
hypotension
DISEASE
a MRI without contrast was obtained.There was no evidence for
osteomyelitis
DISEASE
or
discitis
DISEASE
.However he was found to have a severe cervical spinestenosis at several levels with cord impression. The C3-4level showed moderate sized antral disc protrusion with
spinal stenosis
DISEASE
and
compression of the spinal cord
DISEASE
in C3nerve roots. C4 side has mild disc bulge with mild
compression of spinal cord
DISEASE
and C4 nerve roots. C5-6 showedmild disc bulge with mild
compression of the spinal cord
DISEASE
andC5 nerve roots. C6-7 showed mild disc bulge with no evidenceof
compression
DISEASE
. Neurosurgery was consulted regarding thesefindings. They felt that the spinal
cord compression
DISEASE
was nota neurosurgical emergency. They did not feel that steroidswere indicated in this situation. Neurosurgery recommended afollowup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as an outpatient. Neurologicalexam was nonfocal and the patient did not have any
numbness
DISEASE
weakness tingling
DISEASE
or
incontinence
DISEASE
. The patient was given asoft cervical neck collar to wear at all times except whenhe is sleeping.CONDITION ON DISCHARGE: Hemodynamically stable ambulatingwithout assistance and breathing in room air.DISCHARGE STATUS: The patient is discharged to home with asoft cervical neck collar.DISCHARGE DIAGNOSES: Hypotension due to
hypovolemia
DISEASE
.
Anemia
DISEASE
due to
B12 deficiency
DISEASE
.Non anion gap
metabolic acidosis
DISEASE
.
Acute renal failure
DISEASE
due to
obstruction
DISEASE
and possible acute
tubular necrosis
DISEASE
.Severe
cervical spine stenosis
DISEASE
with
cord compression
DISEASE
.
Abdominal aortic aneurysm
DISEASE
.
Hyperkalemia
DISEASE
.DISCHARGE MEDICATIONS:1. Aspirin 81 mg p.o. q.d.2. Vitamin B12 [**2097**] mcg p.o. q.d.3. Multivitamins p.o. q.d.The patient was asked to not take his metoprolol orlisinopril until he saw his primary care physician.FOLLOW UP: The patient was given the phone number to callDr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of neurosurgery to discuss his spinal stenosisand
cord impingement
DISEASE
.The patient is scheduled to follow up with Dr. [**First Name8 (NamePattern2) 487**][**Last Name (NamePattern1) **] in cardiology on [**2102-8-15**].The patient is asked to follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 665**] inone to two weeks. [**Name6 (MD) **] [**Last Name (NamePattern4) **] [**MD Number(1) 9565**]Dictated By:[**Doctor Last Name 9566**]
MEDQUIST36D: [**2102-5-26**] 15:53:26
T: [**2102-5-28**] 06:06:26Job#: [**Job Number 9567**]Admission Date: [**2105-2-12**] Discharge Date: [**2105-3-2**]Date of Birth: [**2043-7-3**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 3151**]Chief Complaint:productive
cough fever
DISEASE
Major Surgical or Invasive Procedure:intubationbronchoscopyHistory of Present Illness:Mr. [**Known lastname 7931**] is a 61-year-old male w/ recently diagnosed multiple
myeloma
DISEASE
during an admission to an OSH for
pneumonia
DISEASE
whocurrently presents with productive
cough
DISEASE
(yellow/brown andbloody) subjective
fever
DISEASE
chillls x 3 days. Admits to increased
fatigue
DISEASE
and increased
shortness of breath
DISEASE
(which has never beenthis bad before) but denies
myalgias nausea vomiting
DISEASE
abdominal pain diarrhea chest pain palpitations
DISEASE
. Says hefeels exactly like he felt in [**Month (only) 404**] when he had PNA. Recentlydischarged from [**Hospital1 18**] [**2105-2-7**] for treatment of
hypercalcemia
DISEASE
[**1-23**]to
multiple myeloma
DISEASE
. Had been feeling well when discharged butreturned to work Monday [**2-9**] which is when he began to fell ill..In ED had CXR suspicious for LUL and RLL PNA. Given 1 dose ofLevaquin 500 mg IV 1 dose of Vancomycin 1 g IV 80 mEq KCL andmotrin 400 mg po. Admitted to medicine for treatment of PNA.Past Medical History:-Multiple Myeloma with
hypercalcemia
DISEASE
diagnosed [**12-28**]-Muscle invasive bladder CA status post radical prostatectomyand cystectomy in [**2091**] with creation of neobladder-Hypertension-AAA with slight interval increased size last measured [**7-27**]-h/o MI and CAD s/p RCA stenting in [**2099**]-EF of 60-65% [**12-28**]-DVT in his upper extremity in [**2101**]-COPD-Tobacco use 51 pack/year history-Pneumonia in [**7-/2104**] [**12/2104**] (LUL)-Recently diagnosed
AFib
DISEASE
on [**2105-1-7**] for which he is on Coumadin.-Basal cell carcinoma on his right cheek [**2098**]-Spinal stenosis-B12 deficiencySocial History:He lives in [**Hospital1 **] and works as a bartender. He has beenmarried for 21 years. He has a daughter who is 19 years old andlives with him. He has two other daughters that are estrangedfrom him. He smoked a pack per day since [**2053**] but claims to onlysmoke [**3-26**] cigarettes a day currently. He drinks two to three rumdrinks a day he uses marijuana daily.Family History:Significant for a mother who is deceased with
breast cancer
DISEASE
and[**Month/Day (1) 1902**] after MI at age 60. His father died at age 71 and had
Alzheimer's disease
DISEASE
. He has one brother with
diabetes
DISEASE
hypertension
DISEASE
and
coronary artery disease
DISEASE
.Physical Exam:VS: T 96.7 (100.0 in ED) P 72 BP 140/64 RR 20 Pox 98%
RA
DISEASE
GEN: slightly uncomfortable with SOB
irritable
DISEASE
bloody mucus intissue in trash can at bedside.HEENT: PERRL anicteric sclerae. Oropharynx moist without
erythema lesion
DISEASE
or thrush.NECK: Supple.CV: RRR no MGRC.LUNGS: poor air movement diffusely LUL Admission Date: [**2125-6-19**] Discharge Date: [**2125-6-25**]Date of Birth: [**2091-7-1**] Sex: MService: MEDICINE
Allergies
DISEASE
:BetadineAttending:[**First Name3 (LF) 1711**]Chief Complaint:DOEMajor Surgical or Invasive Procedure:NoneHistory of Present Illness:HPI:33M with pmh of borderline htn presenting with
complaint
DISEASE
of newPND and DOE. Pt was in his USOH until 2 weeks prior when hebegan to have difficulty sleeping due to waking up aftersleeping for Admission Date: [**2181-5-20**] Discharge Date: [**2181-6-19**]Date of Birth: [**2133-9-15**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Zosyn / SeroquelAttending:[**First Name3 (LF) 1406**]Chief Complaint:
cardiac arrest
DISEASE
Major Surgical or Invasive Procedure:[**2181-5-26**] Endotracheal intubation[**2181-5-27**] PICC placement[**2181-5-31**] central line placement[**2181-6-11**] cardiac catheterization[**2181-6-15**] Coronary artery bypass graft surgery x 5 (leftinternal mammary artery Admission Date: [**2119-8-15**] Discharge Date: [**2119-9-1**]Date of Birth: [**2065-1-10**] Sex: FService: MEDICINE
Allergies
DISEASE
:CodeineAttending:[**First Name3 (LF) 2145**]Chief Complaint:VFib arrestMajor Surgical or Invasive Procedure:cardiac catheterization and stentingblood transfusionsAICD placementintubationcentral line placementHistory of Present Illness:Ms [**Known lastname 9581**] is a 54 y/o F with
DM2 HTN 3vCAD
DISEASE
(s/p MI s/p RCAstent in [**2110**]) EtOH and
tobacco abuse
DISEASE
h/o depression/[**Hospital 9582**]transferred to the [**Hospital1 18**] CCU on [**8-15**] from [**Hospital 487**] Hospital for
VF arrest
DISEASE
on [**8-14**] shocked in the field.Pt was in her USOH until [**8-14**]. In the evening she cooked dinnerfor her husband then watched a movie and went to bed. At around1am she woke her husband up with
substernal chest pain
DISEASE
. Shethook sublingual NTG which resolved the
pain
DISEASE
immediately.Approximately 15minutes later the patient again experience
chest pain
DISEASE
. Her husband called 911 and by the time he returnedto her side she began to slump in her chair and becameunconscious eyes Admission Date: [**2116-9-12**] Discharge Date: [**2116-9-22**]Date of Birth: [**2069-1-3**] Sex: FService: MEDICINE
Allergies
DISEASE
:IodineAdmission Date: [**2179-3-21**] Discharge Date: [**2179-3-26**]Date of Birth: [**2114-2-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:Doxepin / Levofloxacin / Oxycontin / Benzodiazepines / AtivanAttending:[**Last Name (NamePattern1) 293**]Chief Complaint:
Hypotension
DISEASE
Major Surgical or Invasive Procedure:Right Internal Jugular Central Venous Catheter Placement [**2179-3-21**]Tracheal Tube ChangeHistory of Present Illness:64 year-old gentleman with MMP history of
lung cancer
DISEASE
s/p rightpneumonectomy in [**2174**] severe
COPD
DISEASE
recently discharged from[**Hospital1 18**] MICU [**2178-12-2**] s/p tracheostomy and [**Month/Day/Year 282**] placement afteradmission for
respiratory failure
DISEASE
due to
pneumonia
DISEASE
nowre-admitted to [**Hospital1 18**] with hypotension
tachycardia
DISEASE
and
UTI
DISEASE
..In the ED RIJ placed he was given 4L IVF and started on CTX.CT head no
ICH
DISEASE
CXR Admission Date: [**2117-7-15**] Discharge Date: [**2117-7-27**]Date of Birth: [**2069-1-3**] Sex: FService: MEDICINE
Allergies
DISEASE
:IodineAdmission Date: [**2189-7-15**] Discharge Date: [**2189-7-19**]Date of Birth: [**2120-1-7**] Sex: MService: MICU KURLACHIEF COMPLAINT: Found down in setting of gastrointestinalbleed.HISTORY OF PRESENT ILLNESS: This is a 69-year-old male withhistory of mental retardation with IQ of 60
peptic ulcer
DISEASE
disease with a history of
gastrointestinal bleed
DISEASE
andguaiac-positive stools as well as
asthma depression
DISEASE
with
psychotic seizures
DISEASE
and hospitalization for
suicidal ideation
DISEASE
with plan who was brought to the Emergency Room by EmergencyMedical Service after being found down by brother in pool ofred blood around face and mouth the morning of admission.Brother reports has a history of falls over the last two tothree years ago but none recent. Was in usual state ofhealth until found
bleeding
DISEASE
this morning. Says that hisbrother was able to converse appropriately and en route tohospital family reports that patient vomited black materialand shortly became obtunded.In the Emergency Room vital signs included a temperature of96.1 F a pulse of 112 a blood pressure of 170/65respiratory rate of 12 and he was satting 94%. The patientwas somnolent to following commands. Orogastric lavage wasdone with return of coffee grounds which cleared with 400 cc.Patient was intubated thereafter for airway protection andtransfused two units of red cells for an initial hematocritof 31 and bolused with three liters of normal saline. He wastransiently
hypotensive
DISEASE
to the systolic 80s after intubationin the setting of some
rigors
DISEASE
with a tympanic temperature of92. He was bolused with warm fluids and started on a warmingblanket. He also received Clindamycin for questionaspiration.PAST MEDICAL HISTORY:1. Mental retardation IQ of 60.2. Chronic
constipation
DISEASE
with multiple admissions.3. Hypercholesterolemia.4. Asthma.5. Hiatal hernia.6. GERD with
Barrett's esophagus
DISEASE
as well as
peptic ulcer
DISEASE
disease with history of UGVI and history of guaiac-positivestools.7. History of [**Female First Name (un) 564**]
esophagitis
DISEASE
.8. Depression with
psychotic
DISEASE
features and
suicidal ideation
DISEASE
.9. Iron-deficiency
anemia
DISEASE
.10. BPH status post TURP.11.
DJD
DISEASE
.12.
Nasal polyps
DISEASE
.PAST SURGICAL HISTORY:1. Hernia repair bilaterally.2. Wedge resection of benign right apical lung mass.3. TURP.SOCIAL HISTORY: Patient lives with brother who also hasmental retardation. No tobacco alcohol or drugs.Independent with activities of daily living. Health careproxy is [**Name (NI) 3065**] [**Name (NI) **] at [**Telephone/Fax (1) 9603**].MEDICATIONS ON ADMISSION:1. Accolate 20 b.i.d.2. Lipitor 10.3. Carafate 1 gram b.i.d.4. Celexa 80 q. h.s.5. Colace 100 t.i.d.6. Fleet enema.7. Flovent inhaler.8. Lactulose b.i.d.9. Lasix 10 b.i.d.10. Protonix 40 q.d.11. Serax 30 h.s.12. Serevent MDI.13. Vitamin C.14. Volmax 4 mg b.i.d.15. Wellbutrin 150 mg b.i.d.16. Zyprexa 2.5 mg b.i.d. and 2 mg q. h.s.17. Niferex 150 b.i.d.ALLERGIES: He has no known
drug allergies
DISEASE
.PHYSICAL EXAMINATION: Initial physical exam was significantfor the patient being intubated disheveled with somerigors. Pupillary exam was normal. Patient was in aC-collar. He had poor air movement bilaterally withinspiratory and expiratory wheezes throughout. Cardiac andabdominal exams were unremarkable. Toes were downgoing. Hewas unresponsive to voice. He had no gag reflex but did havecorneal reflexes. Gastrointestinal fellow exam in ER showeda finding of brown stool which was heme negativeAdmission Date: [**2192-1-17**] Discharge Date: [**2192-1-23**]Date of Birth: [**2120-1-7**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 898**]Chief Complaint:
dyspnea
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Mr. [**Known lastname **] is a 72 year old male with history of mentalretardation [**Known lastname **] (see below) who presented to [**Hospital1 18**] from hisadult day care center yesterday after having increasing
dyspnea
DISEASE
and
wheezing
DISEASE
despite increased nebulizer use. Patient also notedto have non-productive
cough
DISEASE
no other URI symptoms. No
headache myalgias
DISEASE
no known
fevers
DISEASE
at home. No known sickcontacts but attends day program..In ER patient was uable to perform peak flow and was givencontinuous nebs then peak flowAdmission Date: [**2123-4-8**] Discharge Date: [**2123-5-1**]Date of Birth: [**2048-8-27**] Sex: FService: [**Year (4 digits) **]
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 6736**]Chief Complaint:
Weakness lightheadedness
DISEASE
worsening
hematuria
DISEASE
Major Surgical or Invasive Procedure:1. Left selective renal angiography - [**2123-4-8**] - InterventionalRadiology2. Right percutaneous nephroureteral stent change - [**2123-4-14**] -Interventional Radiology3. Left antegrade ureteroscopy - [**2123-4-17**] - Dr. [**First Name (STitle) **] [**Name (STitle) **]4. Aortogram Left internal and external iliac arteriograms -[**2123-4-22**] - interventional radiology5. Cystoscopy left ureteral stent removal - [**2123-4-23**] - Dr. [**First Name (STitle) **][**Name (STitle) **]6. Right percutaneous nephroureteral stent removal placement ofright percutaneous nephrostomy tube bilateral ureteral balloonocclusion bilateral antegrade nephrostograms.7. Aortogram Left common internal and external iliacarteriogram coil embolization of left internal iliac artery -[**2123-4-24**] - interventional radiology8. Placement of PICC line - [**2123-4-29**] - interventional radiology9. Left common internal and external iliac arteriogram -[**2123-4-30**] - interventional radiologyHistory of Present Illness:74 F with h/o
colon cancer
DISEASE
s/p chemotherapy and pelvic radiationc/b colovesical fistula and colostomy. She also has a historyof chronic bilateral
ureteral obstruction
DISEASE
for which she ismanaged by bilateral percutaneous nephroureteral stents that areperiodically changed. She developed
hematuria
DISEASE
around the time ofL percutaneous nephroureteral stent change [**2123-3-30**] and underwentselective angiography of left kidney with selective embolization of a
left renal angiodysplasia
DISEASE
[**2123-4-1**]. Her Hct on dischargewas 28.Tonight she felt
hematuria
DISEASE
worsened Admission Date: [**2141-7-29**] Discharge Date: [**2141-8-1**]Date of Birth: [**2088-8-13**] Sex: MService: CCUCHIEF COMPLAINT:
Syncope
DISEASE
.HISTORY OF PRESENT ILLNESS: This is a 52 year old gentlemanwith a past medical history significant for transientcomplete
heart block
DISEASE
who presented through the EmergencyDepartment status post a
syncopal
DISEASE
episode at home. Thepatient reports that on the morning of admission he had anepisode of
dizziness
DISEASE
and a feeling that his head was veryheavy while he was breathing. The patient got up to use thebathroom and had a
syncopal
DISEASE
episode while arising from thetoilet. The patient struck the left side of his head and had
loss of consciousness
DISEASE
for a few seconds. The patient thenpresented to the Emergency Department for further evaluation.The patient reports that the incident at home was notassociated with
shortness of breath
DISEASE
but does report very dull
pain
DISEASE
/ dull pressure sensation in his chest.In the Emergency Department the patient had several moreAdmission Date: [**2108-6-29**] Discharge Date: [**2108-7-3**]Date of Birth: [**2049-3-3**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Atenolol / MetoprololAttending:[**First Name3 (LF) 922**]Chief Complaint:
Chest pain
DISEASE
Major Surgical or Invasive Procedure:[**2108-6-29**] Coronary bypass grafting x 5: Left internal mammaryartery to left anterior descending coronary arteryAdmission Date: [**2167-11-16**] Discharge Date: [**2167-11-21**]Date of Birth: [**2096-11-19**] Sex: MService:HISTORY OF PRESENT ILLNESS:Patient was a 70-year-old male with a 10 year history ofexternal retrosternal chest discomfort that occurredperiodically while exercising. The patient however is veryactive and prior to having shoulder surgery in [**5-24**] wasbiking up to 25 miles a day. Because of the shouldersurgery the patient's level of physical activity has sincethen been diminished.The patient was scheduled for an exercise stress test on[**2167-10-16**] where he exercised for 11 minutes and achieved 84%of his predictable heart rate. The patient had somesubsternal chest discomfort and had electrocardiogram changeswith ST segment depressions of [**12-23**].5 mm inferolaterally.Imaging revealed a mild partially reversible septal defect.The patient's ejection fraction of 67%. The patient wasreferred to the [**Hospital1 69**] for anoutpatient cardiac catheterization.PAST MEDICAL HISTORY:1.
Hypertension
DISEASE
.2.
Loss of hearing of left ear
DISEASE
due to
scarlet fever
DISEASE
(hearingaid).3. Decreased testosterone.4.
Pituitary microadenoma
DISEASE
- 6 mm.PAST SURGICAL HISTORY:1. On [**5-/2167**] right rotator cuff repair.2. Mastoid surgery in the past.ALLERGIES:No known drug
allergies
DISEASE
.MEDICATIONS:1. Aspirin 81 mg po q day.2. Norvasc 5 mg po q day.3. Testosterone injections every three weeks.HOSPITAL COURSE:Patient was admitted to the [**Hospital1 188**] on [**2167-11-16**] for cardiac catheterization. He was foundto have left main and
multivessel disease
DISEASE
and CardiothoracicSurgery was consulted. Decision was made to take the patientfor coronary artery bypass graft.The patient underwent bypass surgery on [**2167-11-17**] with hisleft internal mammary being grafted to the left anteriordescending artery and with saphenous vein graft to the PDAthe OM and the diagonal.The patient was thereafter transferred to the SICU forcontinued monitoring. The patient had an uncomplicatedpostoperative course and was transferred to theCardiothoracic Surgery floor on postoperative day #1. Thepatient's
pain
DISEASE
was well controlled. Physical therapy wasinitiated and the patient was able to tolerate activitywell.On postoperative day #3 the patient complained of epigastricdiscomfort aggravated by talking. The patient had a benignabdominal examination and was still passing flatus althoughhe had not yet had a bowel movement. The
pain
DISEASE
was not
anginal
DISEASE
in type. Decision was made to order the serumamylase test to evaluate for
pancreatitis
DISEASE
. The test wasnegative with an amylase coming back at 40.By postoperative day #4 the patient was deemed stable fordischarge to home. At the time of discharge the patient hadscratchy voice that was suspected to be caused by hisintubation during surgery. The patient was instructed tocontact Dr. [**Last Name (STitle) 70**] if his voice quality did not improve inthe days following discharge.DISCHARGE CONDITION:Stable.DISCHARGE MEDICATIONS:1.
Enteric
DISEASE
coated aspirin 325 mg po q day.2. Colace 100 mg po bid.3. Lasix 20 mg po bid.4. Potassium chloride 20 mEq po bid.5. Motrin 400 mg po q6-8h prn.6. Dilaudid 1-2 tablets po q4-6h prn (The patient did notrequire beta blockade because he had a resting heart rate inthe 60s-70s).FOLLOWUP:The patient is to followup with Dr. [**Last Name (STitle) 70**] six weeksfollowing discharge. The patient is asked to followup withhis primary care physician [**Last Name (NamePattern4) **] [**1-26**] weeks following discharge. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] M.D. [**MD Number(1) 75**]Dictated By:[**Name8 (MD) 997**]MEDQUIST36D: [**2167-11-22**] 12:29T: [**2167-11-25**] 06:53JOB#: [**Job Number 9629**]Admission Date: [**2110-3-31**] Discharge Date: [**2110-4-10**]Service: Cardiac SurgeryNOTE: Date of discharge pendingAdmission Date: [**2112-6-26**] Discharge Date: [**2112-7-1**]Date of Birth: [**2043-4-18**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:No Known Allergies / Adverse Drug ReactionsAttending:[**First Name3 (LF) 1505**]Chief Complaint:
Exertional dyspnea
DISEASE
Major Surgical or Invasive Procedure:[**2112-6-27**] Aortic valve replacement (23mm St. [**Male First Name (un) 923**] Regent mechanicalvalve)History of Present Illness:69 year old gentleman with a complex past medical history whohas known
coronary artery disease
DISEASE
status post angioplasty and
aortic stenosis
DISEASE
followed by serial echocardiogram. He hasrecently noticed increased
dyspnea
DISEASE
on exertion. Echo earlierthis year showed severe
aortic stenosis
DISEASE
with [**Location (un) 109**] 0.76cm2. He wasreferred for a cardiac catheterization which revealed nosignificant
coronary disease
DISEASE
and mild
aortic stenosis
DISEASE
. Hepresents now to see if his
dyspnea
DISEASE
is related to his aortic
valve disease
DISEASE
and if he should proceed with surgery. Of notepulmonary function testing and a chest CT scan were notsuggestive of any disease process which may be responsible forhis
exertional dyspnea
DISEASE
.Past Medical History:
Aortic stenosis
DISEASE
Hypertension
DISEASE
Dyslipidemia
DISEASE
Diabetes
DISEASE
type 2Paroxysmal
atrial fibrillation
DISEASE
- Cardioversion x2
B cell lymphoma chemo
DISEASE
and xrtProstate CA
Herpes Zoster
DISEASE
Lung CABursitis
Urinary incontinence
DISEASE
s/p artificial sphincterSpinal stenosisS/P right lower lobectomy [**3-/2107**]S/P fatty tumor removal from his back
Prostate cancer
DISEASE
s/p resection and radiationAdmission Date: [**2188-3-9**] Discharge Date: [**2188-3-19**]Date of Birth: [**2108-7-24**] Sex: MService: SURGERY
Allergies
DISEASE
:LatexAttending:[**First Name3 (LF) 668**]Chief Complaint:Reversal of ColostomyMajor Surgical or Invasive Procedure:[**2188-3-10**]: Exploratory laparotomy and takedown of Hartmann'sprocedure.History of Present Illness:This is a 79-year-old male who underwent an abdominal aortic
aneurysm
DISEASE
repair ([**4-18**]) which was complicated by ischemic colonrequiring colostomy/hartmanns procedure ([**2187-4-26**]) complicated by
stomal prolapse 4-5
DISEASE
cm wide presents for reversal of colostomy.Pt was scheduled for barium enema [**2-20**]. Results show normalpouchogram. No evidence of leak. However pt is severely botheredby
stomal prolapse
DISEASE
.Pt has been stable with no new medical issues since discharge.Pt does have intermittent asymptomatic
atrial fibrillation
DISEASE
forwhich he normally takes Coumadin. Pt has had a few episodes of
syncope
DISEASE
in the last year associated with
low blood pressures
DISEASE
.
Last syncopal
DISEASE
episode was [**2187-12-13**]. Pt stopped Coumadin([**3-2**])Plavix ([**3-2**]) and apsrin ([**3-1**]) 4-5 days prior to surgery. Ptwas cleared for surgery by cardiology (Dr. [**Last Name (STitle) **]. RecentECHO ([**2-21**]) shows EF 50-55% with moderate
mitral regurgitation
DISEASE
and only mild
LA enlargement
DISEASE
.Review of symptoms is negativePatient was admitted on [**2188-3-7**] however wanted to delay thesurgery till [**2188-3-10**]. He was discharged on Lovenox and returnstoday for preop eval. Patient reports no new changes in medicalcondition over last two days.Past Medical History:AAA repairbilat renal stents [**2187-4-24**]L hemicolectomy with Hartmanns/colostomy [**2187-4-26**] debridement of
peripancreatic necrosis
DISEASE
[**2187-5-25**]
HTN
DISEASE
Hypercholesterolemia
DISEASE
DM
DISEASE
Afib
DISEASE
(off coumadin)
claudication
DISEASE
vericose veinsGERD
anxiety
DISEASE
Social History:pt denies ETOH cigarettes or illicit drug use. lives with wife.Family History:N/CPhysical Exam:GEN: NAD AOX3Cards: RRR faint
holosystolic murmur
DISEASE
[**2-15**] distant heart soundsLungs: CTABAbd: soft NT non distended. colostomy bag brown stoolSkin: around colostomy no calor/rubor/tumor/dolor or other signsof
infection
DISEASE
.Ext: no
edema
DISEASE
Pertinent Results:On Admission: [**2188-3-9**]WBC-7.5 RBC-3.72* Hgb-12.1* Hct-34.2* MCV-92 MCH-32.6*MCHC-35.5* RDW-13.7 Plt Ct-152PT-13.3 PTT-27.6 INR(PT)-1.1Glucose-91 UreaN-24* Creat-1.3* Na-138 K-4.6 Cl-102 HCO3-29AnGap-12Calcium-9.1 Phos-3.2 Mg-2.0At Discharge: [**2188-3-18**]WBC-10.2 RBC-3.12* Hgb-9.9* Hct-27.9* MCV-90 MCH-31.8 MCHC-35.5*RDW-14.3 Plt Ct-256PT-23.2* PTT-32.7 INR(PT)-2.2*Glucose-111* UreaN-24* Creat-1.3* Na-135 K-3.9 Cl-102 HCO3-28
AnGap-9
DISEASE
Calcium-8.2* Phos-2.5* Mg-2.0Brief Hospital Course:79 y/o male who was admitted for pre-op heparinization and wastaken to the OR for ex lap with reversal of his Hartmans by Dr[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Per operative note the abdomen was free of
adhesions
DISEASE
. The ostomy was successfully taken down and theabdomen was primarily repaired without mesh. He was extubated inthe OR and transferred to the PACU in stable condition.ASA and plavix were restarted on POD 1. A heparin drip wasstarted on POD 2. Coumadin was restarted on pod 2 once PTT wasin range. INR was monitored daily.On POD 3 he developed a rapid heartbeat. 12 lead EKG showed
Atrial fibrillation
DISEASE
with rapid ventricular response. The patientwas asymptomatic however the
Afib
DISEASE
did not respond to 5 mg IVLopressor x 3 doses therefore he was transferred to the SICU fora diltiazem drip. Cardiac enzymes were unremarkable.Cardiology was consulted and recommended uptitrating themetoprolol as BP allowed and titrating off the IV diltiazem.This was done with conversion to PO meds over 2 days with thediltiazem drip stopped. He transferred back to themedical/surgical floor.He was only off the diltiazem one day when he was noted toagain have
atrial fibrillation
DISEASE
. The diltiazem PO was restartedcontrolling his rate. A cardiology follow up with Dr. [**Last Name (STitle) **]was arranged for [**3-26**] to followup the change in regimen as wellas restarting the INR monitoring once he is discharged to home.He developed
diarrhea
DISEASE
on POD 6 and was found to be C. Diffpositive. Six weeks of PO Vanco was recommended by ID. Patientdoes have a prior history of C diff
infection
DISEASE
. He was started onvancomycin 250mg q 6 hours x 10 days. This was started on [**3-17**].Vanco then would decrease to 150mg q 6 hours for 1 week then150mg twice daily for 1 week then 150mg qd x 1 week then 150mgevery other day for 1 week then every 3 days x 1 week.He was screened for MRSA (nasal and rectal)while in the SICU andfound to be positive.The wound incision was clean/dry/intact. The open area at thesite of the ostomy takedown required a small saline wet to drypacking dressing [**Hospital1 **]. This area appeared clean.Coumadin was started at 5mg qd on [**3-12**]. He received this thru[**3-16**]. INR increased to 4.1 on [**3-17**]. Coumadin was held on [**3-17**]. On[**3-18**] 3mg of coumadin was given for INR of 2.2. On [**3-19**] INR was1.5. Coumadin 5mg daily was ordered. This was his home dose. Heshould have daily INRs until stabilized on home dose.Patient was evaluated by PT. He initially had some
orthostatic
DISEASE
hyppotension
DISEASE
but this resolved and he was ambulating using awalker. Rehab was recommended to increase endurance progressdistance ambulated and maximize function. A rehab bed wasavailable at [**Hospital **] Rehab Hospital. He was transferred therein stable condition.Medications on Admission:Asprin 81 mg (stopped Sat [**3-1**])Plavix 75 mg QD (stopped sun [**3-2**])Coumadin 5mg QD (stopped Sat [**3-1**])gabapentin 300mg QDlisinopril 5mg QDmetoprolol 50mg QDsimvastatin 20mg QDDischarge Medications:1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY(Daily).2. Aspirin 81 mg Tablet Chewable Sig: One (1) Tablet ChewablePO DAILY (Daily).3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24hours).4. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3times a day).5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets POQ6H (every 6 hours) as needed.6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H(every 6 hours).7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4PM: inr daily until stable.8. Reglan 5 mg Tablet Sig: One (1) Tablet PO four times a day.9. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every6 hours) for 7 days: then 150 QID x1 week then 150mg BIDx1 wkthen 150mg Qday x1 wk then 150 QOD x1 wk then 1 week of Q3days..10. Insulin Regular Human 100 unit/mL Solution Sig: followsliding scale Injection ASDIR (AS DIRECTED): qidsee printed scale.Discharge Disposition:Extended CareFacility:[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]Discharge Diagnosis:s/p Hartmanns reversal
Atrial fibrillation
DISEASE
C.difficileDischarge Condition:Stable/FairDischarge Instructions:Please call Dr[**Name (NI) 670**] office at [**Telephone/Fax (1) 673**] for
fever
DISEASE
Admission Date: [**2179-4-12**] Discharge Date: [**2179-4-15**]Date of Birth: [**2114-2-8**] Sex: MService: MEDICINE
Allergies
DISEASE
:Doxepin / Levofloxacin / Oxycontin / Benzodiazepines / AtivanAttending:[**First Name3 (LF) 297**]Chief Complaint:altered mental status and
hypotension
DISEASE
Major Surgical or Invasive Procedure:picc line and central accessHistory of Present Illness:65 year-old gentleman with multiple medical problem includinghistory of
lung cancer
DISEASE
post right pneumonectomy in [**2174**] severe
COPD
DISEASE
post tracheostomy and [**Year (4 digits) 282**] placement(respiratory
failure
DISEASE
due to
pneumonia
DISEASE
) recently admitted to [**Hospital1 18**] for
urosepsis
DISEASE
nowpresenting yet again with
hypotension
DISEASE
and altered mental status.Patient unable to give a history at this time so obtained fromrecords. Pt was admitted to [**Hospital1 **] on [**3-26**] after an admissionat [**Hospital1 18**] for a Klebsiella UTI and
hypotension
DISEASE
. Since hisadmission there the pt has been alert and getting out of bed tothe commode with assistance. On [**4-11**] the pt became lethargicand then gradually unresponsive. On [**4-12**] his BP decreased to60 over palp and the pt was noted to be diaphoretic. He receiveda 500 cc bolus with an increase in his BP to 90/40. He remainedunresponsive during this time. ABG showed 7.265/92.7/82 on anFiO2 of 0.50 with a temperature of 99.4. Of note pt's triplelumen was placed [**2179-3-21**]..Wife later arrived at the hospital and was able to provideadditional history. She reports that he had been doing very welluntil Friday. They were working on weaning him and he was ableto be on the trach mask for 1-2 hours at a time. However onFriday the pt felt mildly more SOB per his report. He wasmaintained exclusively on the vent over the rest of the weekend.Yesterday the pt's wife reports that he looked Admission Date: [**2116-7-6**] Discharge Date: [**2116-7-13**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 759**]Chief Complaint:epigastric painvomittingMajor Surgical or Invasive Procedure:noneHistory of Present Illness:Patient is a 85 y/o F with
Myelodysplastic
DISEASE
syndrome/RAEB whopresented to an OSH ED with complaints of
epigastric pain
DISEASE
N/V.She was found to have
leukocytosis
DISEASE
to 28000 and underwent a CTabdomen. The CT revealed bilateral
lower lobe pneumonia
DISEASE
. She wasgiven 500mg Levaquin and transfered to [**Hospital1 18**]. At [**Hospital1 18**] CXRrevealed multifocal air space
opacities
DISEASE
. She was givenCeftriaxone and Vancomycin. She remained HD stable requiring 3L oxygen by N/C. Also noted to have a Troponin of .44 with a negCK and a lactate of 3.8. Currently she complains of continued
epigastric pain
DISEASE
but denies SOB
cough chest pain fever
DISEASE
diarrhea nausea vomiting dysuria
DISEASE
.ROS: As mentioned above the patient had
pain
DISEASE
in abdomen since [**34**]hours before admission. It was in right as well as left upperquadrant no radiation moderately severe did not change withcoughing. She did not have it now. However there is
tenderness
DISEASE
to palpation on exam in right upper quadrant more paraumbilicalthan subcostal. She did not complain of any
nausea
DISEASE
(which shehad on admission) vomitting today. She gives h/o
diarrhea
DISEASE
.The pt did not have any difficulty or
pain
DISEASE
in swallowing nosensation of food getting stuck in the food pipe.No complaints of
fever chills sore
DISEASE
throat. She gives h/o mild
cough
DISEASE
since last 7 days but no sputum production.No h/o
chest pain
DISEASE
. H/o SOB since last 7 days.Past Medical History:- eName: [**Known lastname 395**] [**Known firstname **] Unit No: [**Numeric Identifier 9675**]Admission Date: [**2152-2-9**] Discharge Date: [**2152-2-14**]Service: MedicineHISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old male with
Parkinson's disease dementia
DISEASE
history of aspiration in thepast who was in his usual state of health until the morningof [**2-9**] when he was noted to be unable to get out of bedin the morning secondary to profound
fatigue
DISEASE
. He also notedmild
shortness of breath and cough
DISEASE
productive of yellowishbrown sputum. There were no
fevers
DISEASE
or
chills
DISEASE
no
pleuritic
DISEASE
chest pain
DISEASE
. There was no witnessed aspiration event. Therewere no recent sick contacts but the patient goes to the[**Hospital3 **] Day Care program. Denied falls head
trauma
DISEASE
or
loss of consciousness
DISEASE
. The patient was found byVNA and taken to [**Hospital1 69**]Emergency Room where chest x-ray was consistent with rightlower lobe
pneumonia
DISEASE
. He was hemodynamically stable but thenwas noted to have
hypotensive
DISEASE
episodes to 70/palp with
bradycardia
DISEASE
heart rate in the 30's. There was no responseto Atropine. He was given intravenous fluids with a goodblood pressure response and then admitted to the medicalIntensive Care Unit.PAST MEDICAL HISTORY:
Parkinson's dementia depression
DISEASE
anxiety
DISEASE
coronary
artery disease
DISEASE
status post myocardial
infarction
DISEASE
in [**2104**]
squamous cell carcinoma
DISEASE
of the vocalcords status post excision and XRT hypertension spinal
stenosis BPH
DISEASE
status post TURP.MEDICATIONS: Sinemet 25/100 po tid Diltiazem 180 mg po q dAricept 10 mg po q d Proscar 5 mg po q d Multivitamin onetablet po q d Beconase eyedrops and Clotrimazole.ALLERGIES: No known
drug allergies
DISEASE
.SOCIAL HISTORY: Lives in elder housing very supportivefamily. Daughter's telephone number is [**Telephone/Fax (1) 9676**]. Hercell phone is [**Telephone/Fax (1) 9677**].PHYSICAL EXAMINATION: Vital signs temperature 98.9 bloodpressure 137/75 pulse 70 respirations 20 and oxygensaturation 91% on room air. In general he was alert at timesbut at other times confused. HEENT: Conjunctiva were moistno pallor. Pupils were 2 mm bilaterally reactive. Tonguewas dry. Oral cavity was dry. There is a right facialdroop. Extraocular motions are full. The palate wassymmetric and elevated bilaterally. Sternocleidomastoid andtrapezius were full strength bilaterally. Chest bilateralwheeze and
basilar rhonchi
DISEASE
bilaterally. Cardiac exam wasnormal S1 and S2 regular rate and rhythm and no murmurs.Abdomen was soft and nontender with positive bowel sounds.There is a large right sided inguinal
hernia
DISEASE
that waspartially reducible. The extremities were warm and pulseswere fully palpable distally. Neuro exam 5-/5 strengthglobally.LABORATORY DATA: On admission Chem 7 sodium 140 potassium4.6 chloride 102 CO2 27 BUN 27 creatinine 1.5 and glucose148. CBC white cells 19.8 differential 81% neutrophils 7%bands 2% lymphocytes and 10% monocytes. Hematocrit 39.9 andplatelet count 291000. Urinalysis trace blood 30 protein[**2-1**] red blood cells rare bacteria 0-2 epithelial cells.Chest x-ray right lower lobe
pneumonia
DISEASE
. EKG normal sinusrhythm right bundle branch block left ventricular strain.Blood culture no growth. Urine culture no growth. Sputumculture poor sample contaminated with oropharyngeal flora.IMPRESSION: [**Age over 90 **]-year-old male with
Parkinson's disease
DISEASE
coronary artery disease
DISEASE
history of
vocal cord cancer
DISEASE
presents with
pneumonia
DISEASE
and
hypotension
DISEASE
.HOSPITAL COURSE:1. Infectious disease: The patient's
pneumonia
DISEASE
was treatedwith Levaquin Vancomycin and Flagyl. He improvedsignificantly and was ultimately changed to oral Levaquin andFlagyl. No definitive pathogen was every identified.2. Pulmonary: The patient improved dramatically withantibiotics as stated above. Albuterol and Atrovent nebswere used for several days but were ultimately not needed bythe end of his hospital stay. Chest PT was done. His oxygensaturation improved to 95-97% on room air.3. Cardiovascular: It was assumed that the patient's
hypotension
DISEASE
and
bradycardia
DISEASE
were representative of a briefepisode of
sepsis
DISEASE
. This resolved with IV fluids andantibiotic therapy. Initially his anti-hypertensives wereheld but there were added back once he became hemodynamicallystable.4. Renal: The patient has a mild
renal insufficiency
DISEASE
of a
prerenal
DISEASE
etiology. This resolved completely with IV fluids.His baseline creatinine is 1.5.5. Prophylaxis: The patient was given subcu Heparin andProtonix for prophylaxis. He was able to ambulate well onthe last day of admission and the Heparin was discontinued.In terms of disposition physical therapist felt that thepatient was safe for discharge home. Extensive home serviceswere arranged.DISCHARGE STATUS: He was discharged to home.DISCHARGE CONDITION: Good.DISCHARGE MEDICATIONS: Sinemet 25/100 one tablet po tidCardizem CD 180 mg po q d Aricept 10 mg po q d Proscar 5 mgpo q d Multivitamin one po q d Beconase one spray pernostril [**Hospital1 **] Ophthalmic solution 3.03% one drop each eye q dLotrisone cream topically to the back of legs [**Hospital1 **]Levofloxacin 250 mg po q d until [**2-25**] Metronidazole 500mg po tid until [**2-25**].DISCHARGE DIAGNOSIS:1.
Pneumonia
DISEASE
presumed secondary to aspiration.2.
Parkinson's disease
DISEASE
.3. Hypotension.4. Bradycardia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9678**] M.D. [**MD Number(1) 9679**]Dictated By:[**Name8 (MD) 2734**]MEDQUIST36D: [**2152-6-20**] 19:16T: [**2152-6-24**] 15:47JOB#: [**Job Number 9680**]Admission Date: [**2138-7-14**] Discharge Date: [**2138-7-28**]Date of Birth: [**2059-4-21**] Sex: MService: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 6195**]Chief Complaint:Difficulty swallowing.Major Surgical or Invasive Procedure:PEG placement.History of Present Illness:This is a 79 y/o male patient with
multiple system atrophy
DISEASE
(aggresive form of
Parkinsons
DISEASE
)
HTN
DISEASE
prostate ca s/p XRT who wasinitially admitted to neurology service on [**7-14**] for
dysphagia
DISEASE
secondary to rapid deterioration of MSA and PEG placement. PEGplacement successful but after patient had sudden Hct drop andon CT scan was found to have right RP and thigh bleed
hematoma
DISEASE
unknown etiology transferred to MICU. Vascular consulted andfelt surgery and angio no indicated at present time as patientwould require intubation. Patient was transfused a total of 9units of blood while in the MICU. Patient last blood transfusionwas on [**2138-7-25**] in the am and Hct has been stable. For the pastfew days patient neurologic function has become worse wherepatient very stiff. Neurology following patient for managementof MSA. Patient also noted to be
hypernatremic
DISEASE
in the MICU andis being given free water bolus through PEG tube. Duringhospital course patient had
thrombocytopenia
DISEASE
as well
HIT
DISEASE
sentwhich came back negative plt count starting to improve. Hecontinue to spike low grade
fevers
DISEASE
patient pan-cultured with nosource of
infection
DISEASE
found CXR negative.Past Medical History:1.)Multisystem
atrophy
DISEASE
2.)HTN3.)Prostate CA s/p XRT4.)Cervical
radiculopathy
DISEASE
5.)HypercholesterolemiaSocial History:Pt lives with wife and is cared for by multiple aides. He istotally depedent for adl's. Quit tobacco 30yrs ago.Family History:No
neuro disease
DISEASE
Physical Exam:t 98.4 bp 112/59 hr 104 rr 19 spo2 97%ragen- chronically ill appearing elderly male in nadcv- tachy but reg no m/r/gpul- moves air well minimal
bibasilar rales
DISEASE
abd- peg in place soft nt nd nabsback- no sacral
edema
DISEASE
no
bruising
DISEASE
extrm- 1Admission Date: [**2183-3-12**] Discharge Date: [**2183-3-21**]Date of Birth: [**2141-5-14**] Sex: FService:CHIEF COMPLAINT: Mrs. [**Known lastname
5655
DISEASE
**] is a 41-year-old woman with ahistory of systemic
lupus erythematosus hypertension
DISEASE
and
BOOP
DISEASE
who came to the Emergency Department on [**2183-3-12**]for
cough
DISEASE
of two weeks duration and subsequently went intohypoxic
respiratory arrest
DISEASE
was intubated and transferred tothe Medical Intensive Care Unit.HISTORY OF PRESENT ILLNESS: Over the two weeks prior toadmission Mrs. [**Known lastname 5655**] complained of increasing
shortness
DISEASE
ofbreath with a
cough
DISEASE
productive of yellow sputum flecked withblood. She denied any
chills fever chest pain
DISEASE
or
headache
DISEASE
.Shortly before admission she was unable to walk more thaneight feet without having to rest and catch her breath. Shedecided to come to the Emergency Department when she wasunable to walk up a flight of stairs without extreme
shortness of breath
DISEASE
.While at the Emergency Department Mrs. [**Known lastname
5655
DISEASE
**] got up to goto the bathroom and on her return to her stretcherexperienced a
hypertensive
DISEASE
crisis with systolic bloodpressure in the 190s and a heart rate greater than 140. Shebecame tachypneic short of breath confused and pulseoximetry could not be obtained. She continued to be veryshort of breath on 100% nonrebreather. She was intubated forpresumed
respiratory failure
DISEASE
and transported to the MedicalIntensive Care Unit.PAST MEDICAL HISTORY:1. Systemic
lupus erythematosus
DISEASE
diagnosed in [**2173**] with AWA/ds-DNA/anti-[**Doctor Last Name **] positivity.2. Lupus
nephritis
DISEASE
-
membranoproliferative
DISEASE
glomerulonephritis
DISEASE
.3.
Hemolytic anemia
DISEASE
.4. Thrombocytopenia.5. Lupus cerebritis.6. Lupus
peritonitis
DISEASE
[**2179-1-6**].7. Pleuritis.8. Arthritis.9.
Raynaud's syndrome
DISEASE
.10.
BOOP
DISEASE
in [**2179-9-6**].11.
Hypertension
DISEASE
.12. Salmonella
bacteremia
DISEASE
in [**2182-7-6**].13.
TTP
DISEASE
-
HUS
DISEASE
.14. Membranous
glomerulonephritis
DISEASE
with a
necrotizing
DISEASE
component and focal crescent formations mixed Type III/V
lupus erythematosus
DISEASE
.SOCIAL HISTORY: Patient lives in [**Location 669**] with her brother.She works part time as a tax accountant. She has a negativetobacco history. She stopped drinking alcohol in [**2170**]. Shedenies any other drug use. She is not currently sexuallyactive.FAMILY HISTORY: The patient's mother died of
lupus
DISEASE
at theage of 47. She does not know her father well and is unableto report on his health history. She has seven brothers andsisters. Two of her brothers have
alcoholism
DISEASE
. One sisterhas insulin dependent
diabetes mellitus
DISEASE
. There is nosignificant family history of
cancer asthma
DISEASE
or heartdisease.ALLERGIES: Haldol -
acute dystonic reaction
DISEASE
. Sulfa - hivesand
shortness of breath
DISEASE
. Biaxin.MEDICATIONS ON ARRIVAL AT THE EMERGENCY DEPARTMENT:Lopressor 50 mg b.i.d. Zestril 5 mg q.d. prednisone 5 mgq.d. aspirin 81 mg q.d. Lipitor 20 mg q.d. Prilosec 20 mgq.d. Nephrocaps.REVIEW OF SYSTEMS: Chronic
constipation
DISEASE
treated withColace. Joint
pain
DISEASE
significantly worse in winter time with
Raynaud
DISEASE
's. No history of
chest pain
DISEASE
or
palpitations
DISEASE
.PHYSICAL
EXAM
DISEASE
ON ADMISSION TO THE MEDICAL INTENSIVE CAREUNIT: General: intubated sedated middle-aged woman.Vital signs: Blood pressure 140/90. Heart rate 130.Temperature 99.1. Head eyes ears nose and throat: pupilsequal round and reactive to light. Sclerae are anicteric.Neck supple no LAD. Chest: bilateral breath soundsanteriorly. No
wheezing
DISEASE
. Coarse bilateral breath soundsthroughout. Inspiratory crackles. Cardiovascular:tachycardic rhythm no murmurs. Abdomen: soft nontendernondistended normal active bowel sounds. Light brown guaiacnegative stool. Extremities: warm without
edema
DISEASE
. Neuro:
Babinski
DISEASE
downgoing bilaterally. Sedated. Symmetricreflexes.LABORATORIES VALUES ON ADMISSION: White blood cell count2.6 differential 57 neutrophils 2 basophils 25lymphocytes 9 macrophages. Hematocrit 28.2 platelets142000. MCV 82. Sodium 138 potassium 3.7 chloride 98bicarbonate 28 BUN 27 creatinine 7.1 glucose 82.Urinalysis: small amount of blood. Greater than 300 protein.2 red blood cells 1 white blood cell 20 epithelial cells.Electrocardiogram
sinus tachycardia
DISEASE
. Rate 110 normal axis.TWI V4 through V6 lead I.HOSPITAL COURSE: While in the Emergency Department Mrs.[**Known lastname 5655**] received nitroglycerin paste Lasix 80 mg intravenous500 mg levofloxacin heparin per protocol Versed 1-2 mg perhour via IV drip. After intubation in the EmergencyDepartment Mrs. [**Known lastname 5655**] received a bedside echocardiogramwhich showed severe left ventricular systolic functional
depression
DISEASE
and a small
loculated pericardial effusion
DISEASE
. Rightventricular diastolic collapse was present consistent withimpaired filling and
tamponade
DISEASE
. A chest x-ray at the timeshowed
congestive heart failure
DISEASE
with
pulmonary edema
DISEASE
although
pneumonia
DISEASE
could not be excluded. Anelectrocardiogram revealed T wave inversions laterally. Mrs.[**Known lastname 5655**] then underwent CT angiography for
pulmonary embolus
DISEASE
which was negativeAdmission Date: [**2184-7-5**] Discharge Date: [**2184-7-11**]Date of Birth: [**2141-5-14**] Sex: FService: BLUE GENERAL SURGERYHISTORY OF PRESENT ILLNESS: The patient is a 43 year-oldfemale with a history of systemic
lupus erythematosus
DISEASE
and endstage
renal disease
DISEASE
on hemodialysis who presented to theEmergency Department on [**2184-6-26**] with
nausea vomiting
DISEASE
andright upper quadrant
abdominal pain
DISEASE
. The patient was seenthe evening prior in the Emergency Department for biliarycolic with 9 out of 10
pain
DISEASE
. Her liver function tests weresignificant for elevated amylase and lipase. Ultrasound atthat time showed
cholelithiasis
DISEASE
with no evidence of
cholecystitis
DISEASE
or
biliary obstruction
DISEASE
. The patient was senthome where she refrained from eating however returned tothe Emergency Department on the day of admission complainingof
nausea
DISEASE
and
vomiting
DISEASE
of clear
emesis
DISEASE
. Her
abdominal pain
DISEASE
decreased to 4 out of 10. The patient denied
fevers
DISEASE
or
chills
DISEASE
. The patient had flatus and her
last bowel movement
DISEASE
was the morning prior to admission.PAST MEDICAL HISTORY: 1. Systemic
lupus erythematosus
DISEASE
diagnosed in [**2173**]. 2. Lupus
nephritis
DISEASE
leading to end stage
renal disease
DISEASE
on hemodialysis for two years. 3. Hemolytic
anemia
DISEASE
. 4. Thrombocytopenia. 5. Raynaud's. 6.
Hypercholesterolemia
DISEASE
. 7. BOOP diagnosed in [**2179**]. 8.
Hypertension
DISEASE
. 9. Osteoporosis. 10. Cardiomyopathy (EFequals 35 to 40%). 11. Lupus
cerebritis
DISEASE
.PAST SURGICAL HISTORY: Significant for a lung biopsy in[**2179**].ALLERGIES: Sulfa which causes
shortness of breath
DISEASE
andBiaxin.SOCIAL HISTORY: No alcohol use. No tobacco use and no druguse.MEDICATIONS ON ADMISSION: 1. Prednisone 5 mg q.d. 2.Atenolol 100 mg q.d. 3. Zestril 40 mg q day. 4. Lipitor40 mg q.d. 5. Prilosec 20 mg q.d. 6. Phos-Lo 666 mg threeto four tablets each meal. 7. Folate 1 gram q.d. 8.Nephrocaps.PHYSICAL EXAMINATION: Vital signs temperature 97.6. Pulse72. Blood pressure 193/103. Respiratory rate 20. O2 sat100% on room air. In general she was a well appearingAfrican American woman in no acute distress. HEENT pupilsare equal round and reactive to light. Extraocularmovements intact. Anicteric sclera. Chest clear toauscultation bilaterally. Cardiovascular regular rate andrhythm. Normal S1 and S2 with a 2 out of 6 systolic ejectionmurmur. Abdomen soft
decreased bowel sounds
DISEASE
nondistendedtender in the right upper quadrant positive [**Doctor Last Name **] sign noguarding or rebound tenderness. Rectal examination guaiacnegative. Pelvic examination no
cervical motion tenderness
DISEASE
per Emergency Department examination. Extremities warm no
clubbing cyanosis
DISEASE
or
edema
DISEASE
. Left upper extremity AV fistulawith a palpable thrill.LABORATORIES ON ADMISSION: White blood cell count 4hematocrit 35.9 platelets 135 normal differential sodium135 potassium 5.2 chloride 94 bicarb 29 BUN 52creatinine 10.5 glucose 77 ALT 12 AST 12 alkalinephosphatase 59 T bilirubin 0.3 amylase was 234 up from 180lipase 148 which was up from 74. Urinalysis was positivefor bacteria and protein. Ultrasound revealed no gallbladderwall thickening no pericholecystic fluid. It was positivefor
gallstones
DISEASE
. No ductal dilatation and the common bileduct equals 4 to 5 mm. Positive [**Doctor Last Name 515**] sign.HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2184-6-26**] for
gallstone
DISEASE
pancreatitis
DISEASE
. The patient was made NPO except formedications and
pain
DISEASE
was controlled with morphine. She wasalso begun on Cefazolin. Early in the a.m. of [**6-28**] thepatient experienced severe
headaches
DISEASE
and was
hypertensive
DISEASE
to200/100. Initially the patient experienced some left facial
numbness
DISEASE
and twitching of all extremities. At this pointLopressor intravenous was given with response noted morphinewas changed to
Dilaudid
DISEASE
and .5 mg of Ativan was given withresolution of symptoms. The patient went to dialysis laterthat day where she was noted to have a generalized tonicclonic
seizure
DISEASE
lasting three to five minutes with a bloodpressure of 180/100. The patient was not dialyzed. The
seizure
DISEASE
occurred prior to dialysis. The patient denied everhaving
seizures
DISEASE
or a
seizure disorder
DISEASE
before. Neurology wasconsulted and MRI and electroencephalogram were obtained attheir suggestion. MRI revealed no morphological abnormalityof the brain and no shift of intracranial structures. Therewere a few nonspecific fossa of increased T2 signal in thewhite matter of both cerebral hemispheres consistent withsmall
vessel infarct
DISEASE
. No
abnormal intracranial
DISEASE
enhancementwas observed. The electroencephalogram was abnormal with aburst of generalized slowing which is nonspecific for
cerebral dysfunction
DISEASE
but suggests the possibility of deepmidline
brain dysfunction
DISEASE
.The patient was begun on Dilantin 300 mg q.h.s. The patientwas dialyzed on both [**6-29**] and [**6-30**]. Due to the patient againhaving twitching symptoms she was given an additional dose ofDilantin prior to her discharge on [**7-1**] as she initiallyrefused to be loaded with the Dilantin on neurologiesrequest. The patient's abdominal examination remained stablethroughout her stay and was nontender to palpation on herdate of discharge. The patient's amylase and lipase trendeddownward throughout her stay. The patient was tolerating alow fat renal fluid restricted diet well on her discharge andthe patient is to return to the hospital for admission onMonday [**2184-7-5**] after her dialysis treatment for a preopadmission for her laparoscopic cholecystectomy on [**2184-7-6**].The patient will also follow up with neurology in clinic withDr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7431**]. Dr. [**Last Name (STitle) 7431**] provided the patientwith her card and information regarding making anappointment.MEDICATIONS ON DISCHARGE: 1. Keflex 500 mg po q 12 hours.2. Dilantin 300 mg po q.h.s. 3. Prednisone 5 mg q.d. 4.Atenolol 100 mg q.d. 5. Zestril 40 mg q.d. 6. Lipitor 40mg po q.d. 7. Prilosec 20 mg q.d. 8. Phos-Lo 666 mg threeto four tablets each meal. 9. Folate 1 gram q.d. 10.Nephrocaps.CONDITION ON DISCHARGE: Stable.DISCHARGE STATUS: Discharged to home without services.DISCHARGE DIAGNOSES:1. Resolved
gallstone pancreatitis
DISEASE
.2. New onset generalized
tonic clonic seizure
DISEASE
. [**Name6 (MD) **] [**Name8 (MD) **] M.D. [**MD Number(1) 4007**]Dictated By:[**Last Name (NamePattern1) 7432**]MEDQUIST36D: [**2184-7-11**] 17:05T: [**2184-7-13**] 14:07JOB#: [**Job Number 7433**]Admission Date: [**2184-10-14**] Discharge Date: [**2184-10-21**]Date of Birth: [**2108-7-24**] Sex: FService: CT [**Doctor First Name 147**]CHIEF COMPLAINT: The patient is a 76 year old woman with ahistory of MI in the past now referred for outpatientcardiac cath due to a positive stress test.HISTORY OF PRESENT ILLNESS: The patient reports that she hadan
inferior MI
DISEASE
in [**2172**]. She was treated at [**Hospital 4628**] Hospitaland did not have cardiac catheterization at that time. Shehas done well since that time and reports that she is veryactive occasionally still dances with her husband andperforms all activities of daily living independently.
Denies
DISEASE
any symptoms of
chest pain
DISEASE
or
dyspnea
DISEASE
. Also denies
claudication orthopnea edema lightheadedness
DISEASE
. Primarycare provider is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1270**] who she sees on a regularbasis. She was recently at his office for an annual stressecho which was done on [**9-27**]. Patient exercised forthree minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol. EKG revealedinferolateral changes. Echo revealed exercise induced
ischemia
DISEASE
in the LAD distribution evidence of an old inferiorMI. Resting ejection fraction was 35% to 45%. She has beenreferred for outpatient cardiac cath.PAST MEDICAL HISTORY: Significant for
hypertension
DISEASE
hypercholesterolemia
DISEASE
CAD status post MI.PAST SURGICAL HISTORY: Significant for thyroid noduleremoval and
cataract
DISEASE
surgery with lens implantation.ALLERGIES: No known
drug allergies
DISEASE
.MEDICATIONS PRIOR TO ADMISSION: Aspirin 325 mg q.d. Zestril5 mg q.d. Lopressor 50 mg b.i.d. Pravachol 20 mg q.d.triamterene hydrochlorothiazide 37.5/25 mg three times perweek Synthroid 0.125 mg q.d.LABORATORY DATA: White count 5.0 hematocrit 41.4 plateletcount 181. Sodium 141 potassium 4.3 chloride 102 CO2 34BUN 15 creatinine 1.0. INR 1.1.SOCIAL HISTORY: Married lives in [**Location 3146**] with her husband.She does not have any children. Denies cigarette use.Denies alcohol use.FAMILY HISTORY: She has a brother and sister who have bothhad coronary artery bypass grafting in the past.PHYSICAL EXAMINATION: On the day of catheterization heartrate was in the 50s sinus rhythm blood pressure 150/50respiratory rate 20 O2 sat 100%. Neck had no
bruits
DISEASE
. Lungswere clear bilaterally. Heart S1 S2 no murmurs regularrate and rhythm. Abdomen soft nondistended nontender.Right groin with a
hematoma oozing
DISEASE
no bruit. Dorsalis
pedis
DISEASE
2Admission Date: [**2101-2-10**] Discharge Date: [**2101-2-15**]Service: MEDICINE
Allergies
DISEASE
:Patient recorded as having No Known
Allergies
DISEASE
to DrugsAttending:[**First Name3 (LF) 689**]Chief Complaint:
Hyperglycemia
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:Patient is an 86 y/o male with
type II diabetes CAD CHF
DISEASE
EF25% AVR CRI who presents to outpt cardiac clinic in reportedrapid
atrial fibrillation
DISEASE
and
hyperglycemia
DISEASE
. Patient was sent tothe ED and rapid afib resolved but patient found with bloodsugar Admission Date: [**2103-7-17**] Discharge Date: [**2103-7-18**]Service: MEDICINE
Allergies
DISEASE
:BactrimAttending:[**First Name3 (LF) 2297**]Chief Complaint:
Respiratory distress
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:This is an 89 yo M with history of CAD s/p CABG
CHF
DISEASE
secondaryto ischemic CMY with EF 25%
Afib IDDM
DISEASE
who presents from his NHtoday with acute onset
shortness of breath
DISEASE
.In the ED he was initially thought to be in acute heartfailure given that he was
hypertensive
DISEASE
to the 170's so he wasgiven lasix 40mg IV x1 placed on a nitro gtt and bipap. CXRrevealed a large RLL consolidation so the patient was alsocovered for HAP with vanco and
zosyn
DISEASE
but only vanco given. Satswere only 90% on BiPAP at 10/5 FiO2 0.50. Labs were significantfor a large bandemia lactate of 5.1 troponin 0.19 and mild
renal failure
DISEASE
. 10 units of regular insulin was given for afingerstick of 450. Because the patient is DNR/DNI (which wasreconfirmed by the ED with the patient's HCP) he was notintubated and transferred to the MICU for further management.Past Medical History:Anterior MI in [**2088**] Cath showed
LAD disease
DISEASE
s/p LIMA to LAD [**2088**]Aortic Valve Repair - porcine prosthesis for
aortic Stenosis
DISEASE
(valve area 0.9 in [**2088**]) Valve and LIMA done at same surgery
Atrial Fibrillation
DISEASE
Tachy-Brady
DISEASE
syndrome s/p [**Company 1543**] sigma DDI pacemaker [**2100-7-18**]Ischemic
Cardiomyopathy
DISEASE
- EF 25%
Hypertension
DISEASE
IDDM
DISEASE
Dyslipidemia
DISEASE
.Social History:Social history significant as Mr. [**Known lastname 7435**] is a recent widow whopreviously lived alone in [**Location (un) 4628**] but was most recentlydischarged to a rehab facility. Has 5 children four of whichlive close by. He used to work as a butcher. He denies anyhistory of smoking and drinks approximately one drink per nightbut none since [**Month (only) 116**]. He denies any illicit drug use.Family History:His father died at the age of 63 from
liver and rectal cancer
DISEASE
colon ca. metastatic to liverAdmission Date: [**2191-2-23**] Discharge Date: [**2191-3-3**]Date of Birth: [**2124-10-22**] Sex: MService: CARDIOTHORACIC
Allergies
DISEASE
:Avandia / LisinoprilAttending:[**First Name3 (LF) 165**]Chief Complaint:
Chest pain
DISEASE
Major Surgical or Invasive Procedure:Cardiac Catherization [**2191-2-24**]Coronary Artery Bypass Graft (off pump) x2 (Saphenous vein graft-Admission Date: [**2157-12-1**] Discharge Date: [**2157-12-4**]Date of Birth: [**2099-6-29**] Sex: MService: MEDICINE
Allergies
DISEASE
:MorphineAttending:[**Doctor First Name 1402**]Chief Complaint:
Chest Pain
DISEASE
Major Surgical or Invasive Procedure:NoneHistory of Present Illness:The patient is a 58 year old male with a history of DM HTNdyslipidemiaPVD CAD with history of MI who transfered forcardiac catheterization for a question of NSTEMI in the settingof
infection
DISEASE
. As noted the patient has a history of CAD withan MI in [**2152**] for which he PCI to RCA in [**2152**] at [**Hospital1 336**]. Thepatient has not had any further
chest pain
DISEASE
since his MI. Hereports a baseline exercise tolerance of 5 blocks limited byfatigue.The patinet was admitted to [**Hospital1 **] [**Location (un) 620**] on [**11-28**] afterpresenting with complaints of N/V x 1 day. The patients wifewas [**Name2 (NI) 7450**] admitted a few days prior with similar GIsymptoms and was diagnosed with
viral gasteroenteritis
DISEASE
. Onpresentation the patient was found to be
hypotensive
DISEASE
in the 80s
febrile
DISEASE
to 102.9 was treated with IVF and one dose ofCTX/azythro. The patinet denies any diahrea or bloody stool.He had continued n/v
fever
DISEASE
and mild abdominal discomfort. Hewas given continued IVF for supportive care in treatment ofpresumed
viral gastroenteritis
DISEASE
. His chest XR on admission wasunremarkable and he was satting on 96% on
RA
DISEASE
.On the evening of [**11-30**] at the OSH the patient developed acute
shortness of breath
DISEASE
. A CXR was obtained which was concerningto the team for infiltrates. He was reportedly started onCXR/Azythro but no documentation is available that he receivedthose antibiotics. he denies any recent productive
cough
DISEASE
.Blood cultures were also obtained. In this setting the patienthad ocmplaints of
chest pain
DISEASE
similar but less intense thanprior MI. Described chest discomfort as sub-sternal chestpressure scaled to [**4-23**] radiation to the shoulder. This chestdiscomfort was relieved with SLNG. An EKG was obtained whichwas concerning of a question of lateral ST depressions andcardiac markers were elevated. The patient was started inheparin palvix ASA and metprolol and was transfered to [**Hospital1 18**]for cardiac catheterization.While being transported the patient had continued
chest pain
DISEASE
which again was relieved with SLNG. He has been
chest pain
DISEASE
freesince. In the holding area the patient had continued
hypoxia
DISEASE
requiring 100% NRB. He continued to be
febrile
DISEASE
spiking atemperature of 101.6 Cardiac catheterization was deffered andthe patient was admitted to the CCU for futher care.On review of systems he denies any prior history of
stroke
DISEASE
TIA
DISEASE
deep
venous thrombosis pulmonary embolism bleeding
DISEASE
at thetime of surgery
myalgias
DISEASE
joint pains cough hemoptysis
DISEASE
blackstools or red stools. He denies recent
fevers chills
DISEASE
or rigors.He denies
exertional buttock
DISEASE
or
calf pain
DISEASE
. All of the otherreview of systems were negative.Cardiac review of systems is notable for the
absence paroxysmal
DISEASE
nocturnal dyspnea orthopnea ankle edema palpitations syncope
DISEASE
or
presyncope
DISEASE
.Past Medical History:PAST MEDICAL HISTORY:1. CARDIAC RISK FACTORS::
Diabetes Dyslipidemia Hypertension
DISEASE
2. CARDIAC HISTORY:-PERCUTANEOUS CORONARY INTERVENTIONS: PCI to RCA at [**Hospital1 336**] in[**2152**]3. OTHER PAST MEDICAL HISTORY:
Sleep apnea
DISEASE
Hiatal hernia
DISEASE
s/p surgical repair
Depression
DISEASE
GERD
DISEASE
Retinopathy
DISEASE
Gastropathy
Nephropathy
DISEASE
(Baseline 1.6)
PVD
DISEASE
s/p status bilateral infrapopliteal revascularizationCritical PT lesion successfully treated with athrectomy and PTA.Social History:-Tobacco history: Not a current smoker Quit smoking: in the[**2118**]-ETOH: Does not drink alcohol-Illicit drugs: None-Retired courier married with one son.Family History:Father: previous
MIs
DISEASE
Physical Exam:VS: T